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STATE OF CALIFORNIA wf V STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION • FORM B eA COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MART(ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ON ONE REM ❑ 2 INTERIM PERMIT O 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE O 8 TANK REMOVED DBAOR FACILITY NAME WHERE TANK IS INSTALLED: p W . E $-r. LD//3T I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN OI A. OWNER'S TANK I.D.# B. MANUFACTURED BY: 4 Ow ) C. DATE INSTALLED(MO/DAY/YEAR) (y 60 } D. TANK CAPACITY IN GALLONS: II.TANK CONTENTS IFMIISMARKED.COMPLETE ITEM C. T V A. [C 1 MOTOR VEHICLE FUEL 4 OIL B, C. 1e REGULAR O 3 DIESEL ❑ g AVIATION GAS l'1� UNLEADED O 4 GASAHOL ❑ 2 PETROLEUM ❑ 80 EMPTY ❑ 1 PRODUCT ❑ lbUN UNLEADED D ❑ 5 JET FUEL ❑ 7 METHANOL ❑ 3 CHEMICAL PRODUCT O 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED O 99 OTHER (DESCRIBE IN ITEM D. BELOW) D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S.# III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.B,AND C,AND ALL THAT APPLIES IN BOX D AND E A. TYPE OF �❑ 1 DOUBLE WALL F-13 SINGLE WALL WITH EXTERIOR LINER O 95 UNKNOWN pI SYSTEM E 2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTEDTANK) O 99 OTHER B. TANK a i BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ B 100% METHANOL COMPATIBLE WIFRP (PrlmuyTok) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN 99 OTHER ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING C.INTERIOR ❑ 6 GLASS LINING ❑ 6 UNLINED 15r95 UNKNOWN ❑ 99 OTHER LINING IS LINING MATERIAL COMPATIBLE WITH 1OD%METHANOL? YES_ NO— D.CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBGRGLASS REINFORCED PLA#TIS PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE ❑95 UNKNOWN 99 OTHER 'TAQ OC ASAIIQ4lr 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 A(p 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A®1 SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A y 95 UNKNOWN A Y 99 OTHER C. MATERIAL AND A BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A U 4 FIBERGLASS PIPE CORROSION A U 6 ALUMINUM A U a CONCRETE A U 7 STEEL WI COATING A U 8 100% 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 3 99 OTHER V.TANK LEAK DETECTION I VISUAL CHECK L�r 2 INVENTORY RECONCILIATION ❑ 3 VADOZE MONITORING ❑ 4 AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITOR" ❑ 6 TANK TESTING O 7 INTERSTITIALMONITORINS 91 NONE ❑ 95 UNKNOWN E:] 99 OTHER VI.TANK CLOSURE INFORMATION 1.G#TNAATED ATE LABT UfEO(MO/DAYHR) 2.ESTYATED OUANTITV OF S.WAS TANK FILLED WITH SID CE REMAINING GALLONS INERT MATERIAL YES 0 NO THIS F M HAS BEEN COMPLETED LWDER PENALTY OF PERJURY,AND TO THE BEST OF AIY KNOWLEDGE, IS TRUE AND CORWT APPLICANT'S NAME DATE (PRINTED 6#IGNATV LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COU14TY# JURISDICTION# FACILITY# 1 TANK# STATE I.D.# L�L 113 13 u I I I 1 11 IL 9�iS PERMIT NUMBER PERMIT APPROVED BYIDATE PERMIT EXPIRATION DATE / "ORM 9 (7•91) THIS FORM MWT BE AGCO PANTO BT A PERMTI APPLICATION•FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. (� 1�