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STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION • FORM B W COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM MARK ONLY ❑ 1 NEW PERMIT ❑ 0 RENEWAL PERMITCHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE ONE REM ❑ 2 INTERIM PERMIT ❑ N AMENDED PERMIT ❑ 8 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED / DBA OR FACILITY NAME WHERE TANK IS INSTALLED: 13- (016 G 0�7 S«!O I. TANK DESCRIPTION COMPLETE ALL ITEMS-SPECIFY IF UNKNOWN A OWNERS TANK L D.8 B. MANUFACTURED SY: C. DATE INSTALLED(MOCAYIYEAR) 6 D. TANK CAPACITY IN GALLONS: Q O ILTANKCONTENTS IFA-11SMARKEO.COMPLETEITEMC. A. 1 MOTOR VEHICLE FUEL ❑ / OIL B. C. Q G�� 0 DIESEL ❑ 8 AVIATION GAS 2 PETROLEUM ❑ 80 EMPTY 1 PRODUCT ib PREMIUM 4 GASAHOL ❑ 7 METHANOL UNLEADED 5 .MET FUEL ❑ 5 C14EMI:ALPRODLCT 95 UNKNOWN ❑ 2 WASTE 2 LEADED 99 OTHER (DESCRIBE IN ITEM 0. BELOWI D. F(AI)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S.t: III. TANK CONSTRUCTION MARKONE ITEM ONLY IN BOXES A.9.ANOC.AND ALLTHAT APPLIES INSOXDANOE A. TYPE OF ❑-1 11 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM �I.�d�� pS�WGpLE WALL ❑ • SECONDARY CONTAINMENT NAULTEOTANIQ ❑ 88 OTHER Ia B. TANK -"'-STEEL ❑ 2 STAINLESS STEEL ❑ S FIBERGLASS ❑ a STEEL CLAD W1 FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 8 POLYVINYL CHLORIDE r7 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W1FRP (PrimmyT&*) ❑ 9 BRONZE ❑ 10 GALVANUED STEEL ❑ 95 UNKNOWN ❑ 88 07HER C] 1 RUBBER LINED ❑ 2 ALKYD LINING 0 EPDXY LINING ❑ l PHENOLIC LINING C.INTERIOR ❑ S GLASS LINING ❑ 8 UNLINED 98 OTHER LINING D LINING MATERIAL COMPATIBLE WITH 100%METHANOL 7 YES_ NO_ D.CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 COAXING ❑ 0 VINYL WRAP ❑ s FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE 174uT1N-- WN !❑ 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 IF APPLICABLE A. SYSTEM TYPE A U i SUCTION EE7 PRESSURE A U S GRAVITY A U 99 OTHER B. CONSTRUCTION A SINGLE WALL A U 2 DOUBLE WALL A U S LINED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND A U 1 BARE STEEL A U 2 STAINLESS STEEL A U 0 POLWWYL CHLORIDE PVC)A U A FIBERGLASS PIPE CORROSION A U S ALUMINUM A U 8 CONCRETE A U 7 STEEL W/COATNG A U 8 100% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHOOC PROTECTION f% UNI=VVN A U 99 OTHER D. LEAK DETECTIONAUTOMATIC LINE LEAK DETECTOR _ 2 LINE TIGHTNESS TESTING ❑ MONITORING C-] 99 OTHER V.TANK LEAK DETECTION ❑ 1 2 INVENTORY RECONCLATION ❑ 0 VADOZE MONITORING C::] A AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING ANK TESTING ❑ 7 INTERSTITIAL MONITORING ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION 1.ESTIMATED DATE LAST USED(MOIDAYNR) 2.ESTIMATED OUANTITY OF I WAS TANK FILLED WITH VES ❑ NO❑ SUBSTANCE REMAINING GALLONS INERT MATERIAL 7 THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPIICANrS NAME DATE (PWN1[IMII9IMTlRq LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY N JURISDICTION I FACILITY I TANK R /T'jC -� Iz' STATE I.D.# Eil © y n Z PERMIT NUMBER PERMIT APPROVED BYADATE PERMIT EMRATION DATE FORM 8(7411 THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORM A.UNLESS A CURRENT FORM A HAS BEEN FRED. 7 PSAeoNaas