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STATE OF CAUFORMA a STATE WATER RESOURCES CONTROL BOARDUNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM B COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT ❑ S RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 RMANENTLY CLOSED ON$ITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE B TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: l�sC� S� I. TANK DESCRIPTION COMPLETE ALL ITEMS– SPECIFY IF UNKNOWN A. OWNERS TANK 1.D.a S. MANUFACTURED BY: /4 C. DATE INSTALLED(MOIDAYNEAR) 0. TANK CAPACITY IN GALLONS: ILTANKCONTENTS IFA-11S MARKED,COMPLETE ITEM C. A. ❑ t R VEHICLE FUEL ❑ 6 OIL 6, C ❑ taUNLEADEI 7 DIESEL ❑ 6 AVWTION GAS ❑ PETROLEUM ❑ 00 EMPTY 1 PRODUCT ❑ lb PREMIUM] 4 GAS L ❑I 7 METHANOL 7 CHEMICAL PRODUCT ❑ % UNIPIOWN ❑ Z WASTE ❑ 2 LEADEDD 5 TFUEL L� 99 OTHER (DESCRIBE IN ITEM 0. BELONq 0. IF(0.1)IS NOT MARKED. ENTER NAME OF SUBSTANCE STOREO I{'Vt.0 / C vL) v l C.A. S. III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN 80%ESA,B.AND C.AND ALL THAT APPLIES IN BOX O AND A. TYPE OF ❑ 1,166LIBLE WALL ❑ 5 SINGLE WALL WITH EXTERIOR LINER ❑ % UNKNOWN SYSTEM 2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER S. TANK ❑ BARE STEEL ❑ 2 STAINLESS STEEL ❑ S FIBERGLASS ❑ 4 STEELCLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 1W. METHANOL COMPATIBLE W/FRP (Primary TaN) ❑ p BRONZE ❑ 10 GALVANIZED STEEL ❑ % UNKNOWN ❑ W OTHER ❑ 1 RUBBER LINED ❑ 2 ALKYD y8/UNLINED LINING ❑ 2 EPDXY LINING ❑ 4 PHENOLIC LININQ C.INTERIOR 5 GLASS LINING � LINING ❑ L_J ❑ % UNKNOWN 99 OTHER IS LINING MATERIAL COMPATIBLE WITH +W%METHANOL? YES_ NO D.CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ S VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION 91 NONE ❑95 UNKNOWN ❑ 99 OTHER E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION ECUIPMENT INSTALLED(YEAR) IV.PIPING INFORMATION CIRCLE A IFA80VEGROUNDOR U IF UNDERGROUND,BOTH IFAPPLCABLE A. SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A U VI A U 99 OTHER B. CONSTRUCTK)N A U t SINGLE WALL A U 2 DOUBLE WALL A U 9 LINED TRENCH A U 94- N A U 99 OTHER C. MATERIAL AND A U 1 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 6 CONCRETE A U 7 STEELMCOATING A U B 100% METHANOL COMPATIBLE WI A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U % UNKNOWN -gyp OTHER D. LEAK DETECTION ❑ 1 AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE I UH INES$TESTING ❑ MONROgING ❑ W OTHER V.TANK LEAK DETECTION i❑ 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ ZE MONITORING ❑ 4 AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING B TANK TESTING ❑ 7 INTERSTITIAL MONITORING 91 NONE ❑ % UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION 1.ESTIMATED GATE LAST USED(MOIDAY/VR) 2 ESTIMATED WANTFTY OF S.WAS TANK FILLED WITH ,./ SUBSTANCE REMAINING O GALLONS INERTMATE RIAL? YES NO❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANTS NAME Rfl IPmaTEDa 9K.NAtVGATE LCCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW STATE LDA COUNTY* JURISDICTION• FACILITY If TANK s � �o i 0 TF1 = �- � - PERMITNUMER Ti PERMIT APPROVED 8 MAI E BJPERMIT EXP IRATK)u�NDATE L_!lC�l� 3 z ARM B (7-91) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. FOFmIRS