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STATE OF CALIFORNIA �O+ STATE WATER RESOURCES CONTROL BOARD Wym� UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B ry� COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. c"�"°""�� MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ON SITE ONE REM ❑ 2 INTERIM PERMIT ❑ 6 AMENDED PERMIT ❑ 8 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED i DBA OR FACILITY NAME WHERE TANK IS INSTALLED: 2v GGv« Gaoa- I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A. OWNERS TANK 1.0.a 0B. MANUFACTURED BY: 1'b6joq®ZJ C. DATE INSTALLED(MO/DAY/YEAR) C' D. TANK CAPACITY N GALLONS: ZAZ a9 II.TANKC EMS IFA-11SMARKED.COMPLETE ITEM C. A 1 MOTOR VEHICLE FUEL ❑ A OIL B. C. ❑ tAUNLEA ED REGULAR3 DIESEL ❑ 8 AVIATION GAS ❑ 2 PETROLEUM ❑ 50 EMPTY 1 PRODUCT ❑ lb PREMIUM GASAHOL ❑ 7 METHANOL UNLEADED 5 JET FUEL ❑ 3 CHEMCALPRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED 99 OTHER (DESCRIBE N ITEM D. BELOW) D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S. III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.B.AND C.AND ALL THAT APPLIES IN BOX A. TYPE OF ❑ DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM 2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER B. TANK � OBF7ARE STEEL ❑ 2 STAINLESS STEEL 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ e POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP (PrimaryTisk) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 90 OTHER ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 6 PHENOLIC UNING C.INTERIOR ❑ 5 GLA38 LINING ❑6 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER LINING IS LINING MATERIAL COMPATIBLE MATH 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 M IV.PIPING INFORMATION CIRCLE AIFABOVEGROUNDORUIFUNDERGROUND,BOTH IFAPPLICABLE A. SYSTEM TYPE A V SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A 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 4 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEE4 WI COATING A U 8 100% METHANOL COMPATIBLE WIFRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODKJPROTECTION p UNKNOWN A U 99 OTHER D. LEAK DETECTION ❑ I AUTOMATK:LINE LEAK DETECT R ❑ 2 LINE TIGHTNESS TESTING ❑ MONITORING ❑ 99 OTHER V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK E2-'F INVENTORY RECONCILIATION ❑ 3 VAPOR MONITORING❑ 4 AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING ❑6 TANK TESTING ❑ 7 9RERSTITIAL MONITORING ❑ 91 NONE ❑ 96 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION 1.ESTIMATED DATE(AST USED(MO/DAYNR) 2.ESTNATED QUANTITY OF3.WAS TANK FILLED WITH SUBSTANCE REMAINING GALLONS VERT MATERIAL? YES ❑ NO❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANTS NAME DATE IInNNTE9 A 9iGNaTURE1 LOCAL AGENCY USE ONLY THE STATE LD.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION a FACILITY a TANK STATE I.D.# 1 11012 GuD1 PERMIT NUMBER PERMIT APPROVED BY/OATE PERMIT EXPIRATION DATE FORM B (490) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. P0119MILM r