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STATE OF CALIFORNIA a STATE WATER RESOURCES CONTROL BOARDUNDERGROUND STORAGE TANK PERMIT APPLICATION w FORM B COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM MARK ONLY ❑ 1 NEW PERMIT I❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ;❑ 7 PERMANENTLY CLOSED ONE ITEM ❑ 2 INTERIM PERMIT ❑ A AMENDED PERMIT J 6 TEMPORARY TANK CLOSURE i❑ 9 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: Cl" O,L Q C S S 7 I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A. OWNERS TANK I.D.a I S. MANUFACTURED BY: Jaa c V C. DATE INSTALLED(MCIOAYNEAR) Il Io I D. TANK CAPACITY IN GALLONS: (1 p p ILTANKCONTENTS IFA-1 ISMARKED.COMPLETE ITEM C. A. ❑ 1 MOTOR VEHICLE FUEL �^ 6 OIL S. C. ❑ 1 UREG�j 3 DIESEL ',❑ 8 AVIATION GAS ❑ 2 PETROLEUM ❑ SO EMPTY 1 PRODUCT ❑ 10IPREN� UMADE0 �L'J+ 5 ��L ❑ 7 METHANOL ❑ 3 CHEMICALPROOUCT ❑ 95 UNW40WN � WASTE ❑ 2 LEADED �9g OTHER (DESCRIBE IN ITEM D. SELOWI D. IF(A.1)IS NOT MARKED. ENTER NAME OF SUBSTANCE STORED � I- C.A S.a. III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.B.AND C.AND ALL THAT APPLIES IN BOX D AND A. TYPE OF f-" I DOUBLE WALL 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM ❑ 2 SINGLE WALL a SECONDARY CONTAINMENT (VAULTED TANK) 99 OTHER B. TANK ❑ I SAFE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS © a STEEL CLAD Wl FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 8 POLYVINYL CHLOROE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPARBLE WAFRP (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER IJ I RUBBER LINED ❑ 2 ALKYO LINING ❑ 3 EPDXY LINING ❑ A PHENOLIC LINING C.INTERIOR ❑ 5 GLASS LINING 6 UNLINED95 UNKNOWN 99 OTHER LINING �- ❑ ❑ IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO— D.CORROSION ❑ 1 POLYETHYLENE WRAP 2 COATING ❑ 3 VINYL WRAP ❑ a FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE ❑S5 UNKNOWN ❑ 99 OTHER E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PAEVENTION EQUIPMENT INSTALED(YEAM IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND.BOTH IF APPLICABLE A. SYSTEM TYPE A U I SUCTION A U 2 PRESSURE A 3 GRAVITY A U 99 OTHER B. CONSTRUCTION An 1 SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND A U I BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A U A FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 6 CONCRETE A J9 7 STEEL M COATING A U 9 100% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION ❑ 1 AUTOMATIC LINE LEAK DETECTOR 2 LINE TIGHTNESS TESTING ® 3 MONRORNG ❑ 99 OTHER V.TANK LEAK DETECTION I VISUAL CHECK h 2 INVENTORY RECONCILIATION ❑ 3 VADOZE MONITORING ❑ a AUTOMATIC TANK GAUGING❑ 5 GROUNDWA TER MONITORING ❑ 6 TANK TESTING 7 INTERSTITIAL MONITORING ❑ 91 NONE ❑ 95 UNKNOWN C:] 99 OTHER VI.TANK CLOSURE INFORMATION 1.ESTIMATED DATE LAST USED(MOIDAYIYR) I 2.ESTIMATED OUANTRY OF 1 WAS TANK FILLED WITH SUBSTANCE REMAINING GAS INERTMATERIAL? YES ❑ �❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJUR N T ST OF MY KNOWLEDGE IS TRUE AND CORRECT APPLICANTS NAME DATE (PRINTED A WWARAAEK ')Aid%b y'-�6 - S3 LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF4 F6UR NUMBERS BELOW q I COUNTY x JURISDICTION x ACU.IIY x TANK R - STATE LDA = I I I j PERMITNUMBER PERMIT APPROVED BYIOATE PERMIT EXPIRATION DATE THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS FORM (1291) FOR0048.116 1 � �i AoC sej