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UFf<S STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B�,,� rd COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT E:�( 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION a 7 PERMANENTLY CLOSED ONSITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED G DBA OR FACILITY NAME WHERE TANK IS INSTALLED: I. TANK DESCRIPTION COMPLETE ALL ITEMS - SPECIFY IF UNKNOWN A. OWNER'S TANK I. D. x B. MANUFACTURED BY: x2i-vY ^—j C. DATE INSTALLED (MO/DAYNEAR) D. TANK CAPACITY IN GALLONS: //p`, DOD it TAAIV (`()KITIZKTC I c A 1 IC&AAavcn ('OKI OI cTciTcUr A. 1 MO ❑ TOR VEHICLE FUEL 4 OIL 2 PETROLEUM ❑ 80 EMPTY ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN � e, 1 PRODUCT 2 WASTE C 1a REGULAR ❑ 3 DIESEL 6 AVIATION GAS ;-�+' UNLEADED �f-J 1b PREMIUM ❑ 4 GASAHOL ❑ 7 METHANOL UNLEADED ❑ 5 JET FUEL ❑ 2 LEADED ❑ 99 OTHER (DESCRIBE IN ITEM D. BELOW) D. IF (A.t) IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C. A. S. #: III TON K r0NSTR ACTION MARK ONE ITEM ONLY IN BOXES A. B. AND C. AND ALL THAT APPLIES IN BOX D AND E A. TYPE OF ❑ 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM 2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER A U 2 DOUBLE WALL ❑ 1 BARE STEEL El2 STAINLESS STEEL 3 FIBERGLASS J74 STEEL CLAD W/ FIBERGLASS REINFORCED PLASTIC B. TANK MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL 95 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED ❑ 2 ALKYO LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING C. INTERIOR ❑ 5 GLASS LINING 6 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER LINING IS LINING MATERIAL COMPATIBLE ITH 100% METHANOL? YES _ NO_ D. CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER E. SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED (YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED (YEAR) I\/ DIDINI(: IAIFnRnnATInN rioric A icecnvcnAnllNnnG 11 IFIINnFR(;RnI1Nn. ROTHIFAPPI. ICARLE A. SYSTEM TYPE A U 1 SUCTION Alg:)2 PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A 0 SINGLE 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 2 STAINLESS STEEL A U A U 6 CONCRETE A U A U 10 CATHODIC PROTECTION 3 POLYVINYL CHLORIDE (PVC)A(:v4 FIBERGLASS PIPE 7 STEEL W/ COATING A U 8 1001% METHANOL COMPATIBLE W/FRP A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION ❑ 1 AUTOMATIC LINE LEAK DETECTOR 2 LINE TIGHTNESS TESTING ❑ 3 Ip,10NITORIIA ❑ 99 OTHER V TANK I PAK DETECTION ❑ 1 VISUAL CHECK � 2 INVENTORY RECONCILIATION ❑ 3 VADOZE MONITORING ❑ 4 AUTOMATIC TANK GAUGING [:]5 GROUND WATER MONITORINC 7 6 TANK TESTING 7 INTERSTITIAL MONITORING ❑ 91 NONE ❑ 95 UNKNOWN F�4 99 OTHER 5 VI. TANK CLOSURE INFORMATION 1. ESTIMATED DATE LAST USED (MO/DAYNR) 2. ESTIMATED QUANTITY OF 3. WAS TANK FILLED WITH YES ❑ NO ❑ SUBSTANCE REMAINING GALLONS INERT MATERIAL ? i THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANTS NAME DATE (PRINTED d SIGNATURE) MAI Ac; FNCY IISF ONLY THE STATE I.D. NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY # JURISDICTION # FACILITY# ?j TANK # DO STATE I.D.# [!�� 03 1 1 + DERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE TWIC FnDRA em ICT Or ArrnMOAmirn RV A PERMIT APPI ICATInN . FnRM A- UNI FSS A CURRENT FORM A HAS BEEN FILED. Ini q �/ FOR0034 RS