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STATE OF CALIFORNIA a STATE WATER RESOURCES CONTROL BOARDUNDERGROUND STORAGE TANK PERMIT APPLICATION• FORM BCOMPLETE A SEPARATE FORM FOR EAC ANK SYSTEM MARK ONLY ❑ I NEW PERMIT '❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑' 7 PERMANENTLY CLOSED ON SITE ONE ITEM ❑ 2 INTERIM PERMIT 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: 41OL2 S, AG//"TJ/Gtr I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A OWNER'S TANK I.D.6 B. MANUFACTURED BY: �,1- C. DATE INSTALLED(MOIDAY)YEAR) D. TANK CAPACITY IN GALLONS: SSD 9 /J fl.TANK C ENTS IFA-11SMARKED.COMPLETE ITEM C. wc_ A. I MOTOR VEHICLE FUEL ❑ 4 OIL B. C. ❑ I UNBBEGGLEMMMA A 3 DIESEL ❑ g AVIATION GAS ❑ 2 PETROLEUM ❑ 80 EMPTY 1 PRODl1CT IEP IUM 4 GASAHOL 7 METHANOL L❑Nw_NLEADED 5 JETFUEL ❑ ❑ 7 CHEMICAL PRODUCT ❑ % UNKNOWN ❑ 2 WASTE 2 LEADED 99 OTHER (DESCRIBE IN ITEM D. BELOW) D. IF(A.1)IS NOT MARKED. ENTER NAME OF SUBSTANCE STORED C.A.5.11 III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.B.ANO C.ANDALLTHATAPPLIES INBOXD A. TYPE OF ❑ I DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ % UNKNOWN SYSTEM SINGLE WALL ❑ 4/atCONOARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER B. TANK ❑ I BARE STEEL 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEELCLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP (Prim6ryT9nk) ❑ 9 BRONZE 1 ❑ 10 GALVANIZED STEEL ❑ % UNKNOWN ❑ 99 OTHER ❑ I RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING C.INTERIOR ❑ 5 GLASS LINING ❑ 6 UNLINED F-I % UNKNOWN99 OTHER LINING ❑ IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? YES_ NO- D.CORROSION ❑ I POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE ❑ % UNKNOWN ❑ 99 OTHER IV.PIPING INFORMATION CIRCLE A IFABOVEGROUNDOR U IF UNDERGROUND.BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A U I SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A U % 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 STEEL W/COATING A U 8 100% METHANOL COMPATIBLE WIFRP PROTECTION A U 9 GALVANQED STEEL A U 10 CATHODOPROTECTION A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION ❑ I AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING ❑ 3 MO9RORNLA G ❑ 99 OTHER V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VAPOR MONITORING❑ 4 AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING ❑ 0 TANK TESTING ❑ 7 INTERSTRIALMONITORING ❑ 91 NONE ❑ % UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION ANTITYOFh 1.ESTIMATED DATE LAST USED(MO/DAV/YfB 2 SU STANCE R 3 W REMAINING L.� GALLONS IN RT MATE ?H RL LYES ❑ NO 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) LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY 6 JURISDICTION x FACILITY! TANK• DO STATE I.D.# ® = P C) �/ PERMIT NUMBER PERMIT APPROVED BYIDATE PERMIT EXPIRATION DATE II FORM B (490) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. FO MM0414 �� R' �