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STATE OF CAUFORNA STATE WATER RESOURCES CONTROL BOARD i •-"� UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM B (/ :• • ; COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM MARK ONLY ❑ 1 NEW PERMIT ❑ 7 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY RE ONE REM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 8 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED (I DBA OR FACILITY NAME WHERE TANK IS INSTALLED: 4'ril9"VlT -5-7&,,-, 9g z46 J I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A OWNERS TANK L 0.8 i B. MANUFACTURED BY: C. DATE INSTALLED(MO/DAYYEAR) 0. TANK CAPACITY IN GALLONS: V II.TANKC ENTS IFA-11SMARKED,COMPLETEREMF ,L I MOTOR VEHICLE FUEL ❑ 4 OIL B. C. IAUNLGEAOED 0 DIESEL ❑ e AVIATION GAS ❑ 2 PETROLEUM ❑ 80 EMPTY 1 PRODUCT ❑ 10 PREMIUM n 4 ��L ❑ 7 METHANOL ❑ 7 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 UNLEADED L�1 99OTHER , L(DESCRIBE IN ITEM D. BELOW) 0. IF(Aq IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S.8: Ili. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.B.AND C.AND ALL THAT APPLIES IN BOX A. TYPE OF ❑ DOUBLE WALL ❑ 7 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM V2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK ❑ 99 OTHER B. TANK Cpll�l BARE STEEL ❑ 2 STAINLESS STEEL ❑ 7 FIBERGLASS ❑ 4 STEEL CLAD Wl FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ e POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ B 100% METHANOL COMPATIBLE W/FRP (Primmy Twkl ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ W OTHER F7 I RUBBER LINED 1--] 2 D Le1W0 ❑ 7 EPDXY LINING ❑ 4 PHENOLIC LINING C.INTERIOR ❑ 5 CLASS LINING 8 UNLINW ❑ 95 UNKNOWN ❑ 99 OTHER LINING IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? YES_ NO D.CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 7 NYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE UNKNOWN ❑ 99 OTHER IV.PIPING INFORMATI N CIRCLE A IFABOVE GROUND OR U IFUNDERGROUND.BOTHIFAPPLICABLE A. SYSTEM TYPE A 1 SUCTION A U 2 PRESSURE A U 7 GRAVITY A U 99 OTHER S. CONSTRUCTION A U 1 SINGLE WALL A U 2 DOUBLE WALL A U 7 LINED TRENCH 95 UNKNOWN A U 99 OTHER C. MATERIAL AND A U I BARE STEEL A U 2 STAINLESS STEEL A U 7 POLYVINYL CHLORIDE(PVC)A U 4 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 8 CONCRETE A U 7 STEEL V COATING A U 8 100% METHANOL COMPATISLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION ❑ I AUTOMATIC LINE LEAK DETECTOR 2 LWETGHTNESS TESTING 2 MoTNEA GL ❑ 99 OTHER V.TANK LEAK DETECTION FI VISUAL CHECK 2 INVENTORY flECONCILIATIINJ ❑ 3 VAPOR MONITORING❑ 4 AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING 8 TANK TESTING ❑ 7 INTERSTITIAL MONITORING ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION 1.ESTIMATED DATE LAST USED(MOADAYIYR) 2.ESTIMATEOWANTITYOF O.WAS TANK FILL ED WITH SUBSTANCE REMAINING GALLONS WERTMATERIAL7 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 Ivaxrs0 a swx•ne0 LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY 9 JURISDICTION 9 FACILITY 9 TANK 9 STATE I.D.# 01:0d p lelola PERMITNUMBER 7`A Vzo , PERMIT APPROVED SY/GATE PERMIT EXPIRATIO 2 ATE ,5— FORM B (990) TAB FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. PoR00]t&M `'