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STATE OF CALIFORNIA w ,?�� STATE WATER RESOURCES CONTROL BOARD i '. UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B COMPLETE A SEPARATE FORM FOR EACHTANK SYSTEM. c-`�R°"�� MAARKGNLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ONS E ONE REM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED ! DBA OR FACILITY NAME WHERE TANK IS INSTALLED: Zap W, 02eAl Zr. Loos I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN q /O1 A. OWNER'S TANK I.D.# 250 - 3 B. MANUFACTURED BY:lrV A C. DATE INSTALLED(MO/DAYIYEAR) 1� D. TANK CAPACITY IN GALLONS: 1z, Poo ILTANKCONTENTS IFA-1 IS MARKED,COMPLETE ITEM C. A 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C. 1aU ELEAD R 3 DIESEL ❑ 6 AVIATIONGAS ❑ 2 PETROLEUM O SO EMPTY 1 PRODUCT ❑ 1b PREMIUM 4 GAS AHOL ❑ 7 METHANOL UNLEADED C::] 3 CHEMICALPRODUCT ❑ 95 UNKNOWN E::] 2 LEADED 2 WASTE ❑ ❑ 9 L 9 OTHER (DESCRIBE IN ITEM D. BELOW) ❑ D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S.a III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.B,AND C,AND ALL THAT APPLIES IN BOX D AND A. TYPE OF Ld 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM ❑ 2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER B. TANK ® 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 8 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP (PrimaryTank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING C.INTERIOR ❑ 5 GLASS LINING 2q 6 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER LINING IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? YES_ NO_ D.CORROSK)N ❑ i POLYETHYLENE WRAP F7 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLMT* PROTECTION N 5 CATHODIC PROTECTION ❑ 91 NONE ❑96 UNKNOWN ❑ N 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 IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION AO2 PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A V 95 UNKNOWN A V 90 OTHER C. MATERIAL AND A U 1 BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)AW 4 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL W1 COATING A U B 100% METHANOL COMPATIBLE WIFRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION ❑ 1 AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING ❑ INIEMONIRSTITIAL ❑ 99 OTHER V.TANK LEAK DETECTION l%1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VADOZE MONITORING ❑ 4 AUTOMATIC TANK GAUGING ❑ 5 GROUNDWATER MONITORkN ❑ 6 TANK TESTING W 7 INTERSTITIALMONITORWG ❑ 91 NONE ❑ 95 UNKNOWN ❑ 90 OTHER VI.TANK CLOSURE INFORMATION 1.ESTIMATED DATE LMT USEO(MOADAY/YRI 2.BSTWATED QUANTITY OF L WNS M TANK FILLED WITH YES ❑ W � MIBSTANCE REMAINING GALLOINERT MATERIAL? THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRMCT APPLICANT'S NAME DATE (PRINTED A MGNAT9RE9 LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTDN# �FACILITY# � NK�TA # �I STATE IBM1 L 11131510 1 1 1 1 1 E PERMITNUMBER PERMIT APPROVED BYIDATE PERMIT EXPIRATION DATE ROAM B (7-91) THIS FORM MUTT BE ACCO PALM BY A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORM A NU BTW PILED.