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s U"ccs STATE OF CALIFORNIA ' STATE WATER RESOURCES CONTROL BOARD a UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B W '-e a COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ® 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ON S TE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED ` DBA OR FACILITY NAME WHERE TANK IS INSTALLED: Cl z,v-o S-1 -7 5- MATERIAL ❑ 5 CONCRETE 1. I. TANK DESCRIPTION COMPLETE ALL ITEMS - SPECIFY IF UNKNOWN A. OWNER'S TANK I. D. # I B. MANUFACTURED BY: C. DATE INSTALLED (MO/DAY/YEAR) 8 I) D. TANK CAPACITY IN GALLONS: to 10,00 II. TANK CONTENTS IFA-11SMARKED.COMPLETEITFMC. A. 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. la REGULAR C ❑ FADED E:] 3 DIESEL 6 AVIATION GAS ❑ F—]2 PETROLEUM ❑ 80 EMPTY 1 PRODUCT ❑ 1bUN EAIUM ❑ 5 GET FUEL ❑ 7 METHANOL ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED 99 OTHER (DESCRIBE IN ITEM D. BELOW) D. IF (A.1) IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED �s (A wt Qx,d e - C. A. S. a III- TANK CONSTRUCTION MARX nNF IT;:M nNi V IN RnYGQ A a ANn n ANn AI I TWAT ADDI ICC IAI onY n AAin C A. TYPE OF ❑ 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM PKI2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER B. TANK ❑ 1 BARE STEEL ❑ 2 STAINLESS STEEL X 3 FIBERGLASS ❑ 4 STEEL CLAD W/ FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 1009% METHANOL COMPATIBLE W/FRP (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING C. INTERIOR ❑ 5 GLASS LINING E?5' 6 UNLINED ❑ 95 UNKNOWN❑ 99 OTHER LINING IS LINING MATERIAL COMPATIBLE WITH 1009 METHANOL? YES_ NO_ D. CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC f❑� PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE ❑ 95 UNKNOWN 99 OTHER E. SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED (YEAR) �r OVERFILL PREVENTION EQUIPMENT INSTALLED (YEAR) IV. PIPING INFORMATION CIRCLE A IFABOVEGROUND OR U IFUNDERGROUND.BOTHIFAPPLICARLE A. SYSTEM TYPE A U i SUCTION A 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A 1 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 A U A U 2 STAINLESS STEEL A U 6 CONCRETE A U 10 CATHODIC PROTECTION 3 POLYVINYL CHLORIDE (PVC) A (p 4 FIBERGLASS PIPE 7 STEEL W/COATING A U 8 1009 METHANOL COMPATIBLE W/FRP A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION ❑ 1 AUTOMATIC LINE LEAK DETECTOR K2 LINE TIGHTNESS TESTING ❑ 3 TERSTITIAL MONITORING ❑ 99 OTHER V. TANK LEAK DETECTION ❑ 1 VISUAL CHECK 2 INVENTORY RECONCILIATION ❑ 3 VADOZE MONITORING ❑ 4 AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING K 6 TANK TESTING ❑ 7 INTERSTITIAL MONITORING ❑ 91 NONE ❑ 95 UNKNOWN K 99 OTHER <1 r2_ VI. TANK CLOSURE INFORMATION 1. ESTIMATED DATE LAST USED (MO/DAYNR) 2. ESTIMATED QUANTITY OF 3. WAS TANK FILLED WITH SUBSTANCE REMAINING GALL NS INE" ATERIAL? YES NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF P JURY, D T,�6THk#tSkOF,&d*N914LEDGE, IS TRUE AND CORRECT APPLICANTS NAME DATE (PRINTED 8 SIGNATURE) v) \ C,-- VD 7 LOCAL AGENCY USE ONLY THE STATE I.D. NUMBER IS COMPOSED OF THE FOUR MBER ELOW COUNTY # JURISDICTION# FACILI # TANK # STATE I. D.# FTI ❑m ❑I PERMIT NUMBER I PERMIT APPROVED BY/DATE T PERMIT EXPIRATION DATE / FORM B (7.91) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION • FORM A, UNLESS A CURRENT FORM A HAS BEEN FILED. ��J / FOR00346