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A G.9 v STATEOFCAUFORMA ,«oma >� s. STATE WATER RESOURCES CONTROL BOARD i c ' UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM B y itl; COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. ��`��°"�� MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION RMANENTLY CLOSED ON SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 6 AMENDED PERMIT ❑ 8 TEMPORARY TANK CLOSURE B TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: O cp ,,, - I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A. OWNERS TANK I.D.0 S. MANUFACTURED BY: atL C. DATE INSTALLED(MODAWYEAR) D. TANK CAPACITY IN GALLONS: ILTANKCONTENTS IFA-I IS MARKED,COMPLETE ITEM C. A. ❑ 1 TOO VEHICLE FUEL B. C. ❑ IaUN FADEDIIS ❑ 6 AVIATgN GAS REGULAR DIE E PETROLEUM ❑ EMPTY 1 PRODUCT ❑ 1bIL UNLEADED • JET FUEL ❑ 7 METHANOL 3 CHEMICAL PRODUCT 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED 99 OTHER (DESCRIBE IN ITEM D. BELOW) D. IF(XI)IS NOT MARKED. ENTER NAME OF SUBSTANCE STORED Loi. le, c Lo/ C.A.S.A: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A,8,AND C.AND ALLTHAT APPLIES W BOX D AND A. TYPE OF ❑ I UBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM 2 SWGL WALL ❑ 0 SECONDARY CONTAINMENT (VAULTED TANK) ❑ 00 OTHER B. TANK ❑ 1 RE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ ! STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL 5 CONCRETE ❑ 8 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ B 100% METHANOL COMPATIBLE W/FRP (PrimaryTank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER ❑ I RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING 6 PHENOLIC LINING C.INTERIOR ❑ 5 GLASS LINING ❑ 8 UNLINED ❑ 95 UNKNOWN ❑ 90 OTHER LINING — IS LINING MATERIAL COMPATIBLE IMTN 100% METHANOL? YES— NO D.CORROSION ❑ I POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ a FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE ❑95 UNKNOWN O 99 OTHER E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND,BOTH IFAPPLK:ASLE A. SYSTEM TYPE A U I SUCTION A U 2 PRESSURE A O3 G W A U 99 OTHER S. CONSTRUCTION A U I SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U OTHE 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 U 7 STEEL W/COATING A U �B 100% METHANOL COMPATIBLE WffRP w PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 9+iya vL D. LEAK DETECTION ❑ 1 AUTOMATIC LINE LEAK DETECTOR 2 LINE TIGHTNESS TESTING ❑ AMSoT,'RG ❑ 99 OTHER V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ DOZE MONITORING '� d AUTOMATIC TANK GAUGING ❑ 5 GROUNDWATER MONITORING ❑ 6 TANK TESTING ❑ 7 INTERSTITIAL MONITORING 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION 1.ESTIMATED DATE LAST USED(MO/DAY/YR) 2.ESTIMATED DUANTITY OF 3.WAS TANK FILLEDWITH YES NO❑ It D SUBSTANCE REMAINING GALLONS INERTMATERIAL7 THIS FORM HAS BEEN C MPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE IS TRUE AND CORRECT APPLICANTS NAME DATE (PRINT99 a 5 MRIS LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY a JURISDICTION s FACILITY R TANK B �,gAW, O STATE I.D.# Fs-77 FTm 5,131117a PERMIT NUMBER PERMIT APPROVED BY/DATE 7" IT EXPIRATIO ERM DATE 323 �/9 9 FORM B (7-91) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. �, / FOR001/9RS