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STATE OF CALIFORNIA — ,�'t6 c t STATE WATER RESOURCES CONTROL BOARD ,ems e UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B 30 �, o ro COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SfTE ONE REM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ s TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: /3 G O TS ; 0 I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY F UNKNOWN A. OWNER'S TANK I.D.# B. MANUFACTURED BY: C. DATE INSTALLED(MO/DAWYEAR) 6 D. TANK CAPACITY IN GALLONS: S OO II.TANK CONTENTS IFA-1 IS MARKED.COMPLETE ITEM C. OTOR VEHICLE FUEL ❑ 4 OIL B. C. tAUNLEADED e REGULAR 3 DIESEL ❑ g AVIATION GAS A. 6 GASAHOL ❑ 2 PETROLEUM ❑ 80 FlAPTY 1 PRODUCT ❑ 1bPREMIUMUNLEADED 8 5 JET FUEL ❑ 7 METHANOL ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED 99 OTHER (DESCRIBE IN ITEM D.BELOW) D. IF(A.1)IS NOT MARKED. ENTER NAME OF SUBSTANCE STORED C.A.S.S: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.B.ANDC.ANOALLTHATAPPLIES INBOXD A. TYPEOF ❑ 1 OOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEMSINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTEDTANK) ❑ 99 OTHER B. TANK ❑ 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ e POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP (PAmaryTank) ❑ 9 BRONZE ❑ 10 GALVANUED STEEL UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC UNNG C.INTERIOR ❑ 5 GLASS LINING ❑ 8 UNLINED e1-95 UNKNOWN ❑ 99 OTHER LINING IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? YES_ NO— D.CORROSION ❑ I POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE UNKNOWN ❑ N OTHER IV.PIPING INFORMATION CIRCLE A IFASOVEGROUNDOR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U I SUCTION A 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 U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND A U I RARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A U 4 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 8 CONCRETE A U 7 STEEL W/COATING A U 8 100% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A fW36 UNKNOWN A U N OTHER D. LEAK DETECTION I OMATIC LINE LEAK DETECTOR Q..9-tNETIGHTNESSTESTING ❑ J INCT) NG ❑ N OTHER V.TANK LEAK DETECTIO—NI�� F-1 �� ••-VE1 VISUAL CHECK NTORY RECONCILIATION ❑ 3 VAPOR MONITORING❑ 4 AUTOMATIC TANK GAUGING ❑ 5 GROUNDWATER MONITORING K TESTING ❑ 7 INTERSTMALMONRORING ❑ 91 NONE ❑ 95 UNKNOWN ❑ N OTHER VI.TANK CLOSURE INFORMATION 1.ESTIMATED DATE LAST USED(MO/DAY/YR) 2.ESTIMATED OUANTITY OF 3.WAS TANK FILLED WITH VES ❑ NO❑ SUBSTANCE REMAINING GALLONS INERT MATERIAL? THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE IS TRUE AND CORRECT APPLICANTS NAME DATE IvwxrEOasicnZE 77 LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW ��22 COUNTY# JURISDICTION# FACILITY# PJ TANK# µl L.OJo4J LJ STATE I.D.# PERMIT NUMBER PERMIT APPROVED BYIDATE PERMIT EXPIRATION DATE FORM B (9-90) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. IP Fgi0NI8At