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STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD - UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B a A COMPLETE A SEPARATE FORM FOR EAC TANK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY OSED ON SI ONE REM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ S TEMPORARY TANK CLOSURE ❑ B TANK REMOV DBA OR FACILITY NAME WHERE TANK IS INSTALLED: 1. TANK DESCRIPTION COMPETE ALL ITEMS- SPECIFY IF UNKNOWN A. OWNERS TANK I. D.0 8. MANUFACTURED BY: a /C C. DATE INSTALLED (AQ'DAVNEAR) (.f (� D. TANK CAPACITY IN GALLONS: t 22 n ..vrvl Dula IFA•/1S MARKED,COMPLSTE ITEM C. _. -_ _... WALL _.._.... _---.�--..,. ,,, �,,,� �• rv.v n.l � nn� .vrLltJ Iry tlUF U ANU E ❑ 3 SINGLE WALL WITH A. TYPE GF❑� A. ❑ 1 MOTOR VEHICLE FUEL 4 OIL B. 2 PETROLEUM ❑ SO EMPTY ❑ 1 DUCT❑10UNEAIDED 3 CHEMICAL PRODUCT ❑ 95 UNQdOWN 2 WASTE❑ D. IF (&I) IS NOT MARKED, ENTER NAME OFSUBSTANCE STORED rEl 1eRE UNlEADED 2 LEADED 8 3 DIESEL ❑ S AVVITKX/OAS 5 JET FUEL ❑ ?METHANOL 99 OTHER (DESCRIBE IN ITEM D. BELOW) C. W. YIYINL9 INFORMATNJN c]Rn P A IP A9n.0 nR I..P.<.J a A. SYSTEM TYPE _. -_ _... WALL _.._.... _---.�--..,. ,,, �,,,� �• rv.v n.l � nn� .vrLltJ Iry tlUF U ANU E ❑ 3 SINGLE WALL WITH A. TYPE GF❑� /1-,,,pUBE __........ ......ate 3 GRAVI A U 99 OTHER EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM [jdr2)PNGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) ❑ 09 OTHER B. TANK 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEELCLAO W/ FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 5 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ B 100% METHANOL COMPATIBLE W/FRP (PdmMyTWI) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 90 OTHER ❑ 1 RUBBER LINED ❑ 2 KYD LINING ❑ 3 EPDXY UNWO ❑ 4 PHENOLIC LINING C. INTERIOR LINING ❑ 5 GLASS LINING S UNLINED ❑ os UNKNOWN ❑ w OTHER IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO— D. CORROSION ❑ 1 POLYETHYLENE WRAP ❑2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION 01 NONE ❑05 UNKNOWN ❑ 99 OTHER E. SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED (YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED (YEAR) W. YIYINL9 INFORMATNJN c]Rn P A IP A9n.0 nR I..P.<.J a A. SYSTEM TYPE A U 1 SUCTION A U _ _ _.. _ .. _.__.._. __.._. 2 PRESSURE A __........ ......ate 3 GRAVI A U 99 OTHER B. CONSTRUCTION A U 1 liiifLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND CORROSION PROTECTION A U A U A U 1 BARE STEEL 5 ALUMINUM 9 GALVANIZED STEEL A U A U A U 2 STAINLESS STEEL A U a CONCRETE A U 10 CATHODIC PROTECTION 3 POLYVINYL CHLORIDE (PVC)A U 7 STEEL W/COATING A U A U 95 UNKNOWN A U 4 FIBERGLASS PIPE S 100% METHANOL COMPATIBLE W/FRP 09 OTHER D. LEAK DETECTION ❑ 1 AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE IX3H .E33 TESTING ❑ MDNROPOq ❑ 99 OTHER V. I wrn LCAM1Ut I tU I NN F7,1 VISUAL CHECK 2 INVENTORY RECONCILIATION ❑ 3 VADOZE MONITORING ❑ 4 AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING I❑ S TANK TESTING ❑ 7 INTERSTITIAL MONITORING ❑ 91 NONE ❑ 95 UNKNOWN ❑ 9D OTHER VI. IRNK ULASURE INFORMATION 1. ESTIMATED DATE LAST USED (MO/DAYNR) 2. ESTIMATED QUANTITY OF3. WAS TANK FILLED WITH YES ❑ NO ❑ SUBSTANCE REMAINING GALLONS INERTMATERIALr THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY. AND TO THE BEST OF MY KNOW) cnrr IQ MI /c Aun rnMO&ll _ ... _ APPLICANTS NAME (MINTW IGNDATE (PRINTED 8 SATIIREI LOCAL AGENCY USE ONLY THE STATE I.D. NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW STATE I.D.# COUN1TVx JURISDICTIONx FAC TA D. <9BSA64/ ME U PERMIT NUMBER PERMIT APPROVED BYIDATE PERMIT EXPIRATION DATE J Z 3 runty tl (/-r1) .APV . VnM IrYpl oc n..Wm MICU D I A rtMMII Ar FLIUA nuN - rUKM A, UNLESS A CURRENT FORM A HAS BEEN FILED. FORIAIMM