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C� STATE OF CALIFORNIA :` `' STATE WATER RESOURCES CONTROL BOARD W„� .,b'o UNDERGROUND STORAGE TANK PERMIT APPLICATION-FORM B ``-- ,.,� a COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ON SITE ONE REM F-1 2 INTERIM PERMIT ❑ 4 AMENDED PER S TEMPORARY TANK CLOSURE E::] 9 TANK REMOVED 10, DBA OR FACILITY NAME WHERE TANK IS INSTALLED: 1,6 M (.!7 I. TANK DESCRIPTION COMPLETE ALL ITEMS-SPECIFY IF UNKNOWN A OWNERS TANK I.0.0 19 1 1 S. MANUFACTURED BY: U, C. DATE INSTALLED(MO/DAYNEAR) CZ. D. TANK CAPACITY IN GALLONS: f,7)Ogg D ILTANKQWENTS IFMA I3MARKED,COMPLETEITEMC. onI'-� A 1 MOTOR VEHKX.E FUEL ❑ 4 OIL B. C. ❑ 11y8UNLUNEADED u 4 OGASAHOL ❑ 8 AVIATION GAS ❑ 2 PETROLEUM ❑ EMPrT E]/ PREMIUM O 5 JET FUEL ❑ 7 METHANOL ❑ 3 CHEMKCAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE 2 LEADED ❑ 99 OTHER (DESCRIBE N ITEM D. BELOW) D. IF(A1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S.s: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A B,AND C,AND ALL THAT APPLIES IN BOX A TYPE OF ❑ DOUBLE WALL F-13 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM 2 SINGLE WALL F74 SECONDARY CONTAINMENT (VAULTED TANIQ ❑ 99 OTHER 1 BARE STEEL [-] 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B. TANK En MATERIAL 5 CONCRETE F1e POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ S 100% METHANOL COMPATIBLE WIFRP ❑ (Primvy Tmlk) ❑ 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 6 UNLINED ❑ 96 UNKNOWN ❑ W OTHER LINING IB LINING MATERIAL COMPATIBLE WITH 100%METHANOL-7 IIY-JA_ NO— D.CORROSION ❑ I POLYETHYLENE WRAP E:] L 2 COATING _y- VINYL WRAP E::] 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE TpL�I 95 UNKNOWN ❑ W OTHER IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND.BOTH IF APPLICABLE A. SYSTEM TYPE A(U) A SUCTION A u 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION 9 1 SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND AIS I BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A U 4 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 9 CONCRETE A U 7 STEEL W/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 ❑ I AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING ❑ 7 RSTR MONROINGL ❑W OTHER V.TANK LEAK DETECTION ❑ 1 VJSUAL CHECK 2 INVENTORY RECONCILIATION ❑ 3 VAPOR MONITORING E] 4 AUTOMATIC TANK GAUGING ❑ 5 GROUNDWATER MONITORING TANK TESTING ❑ 7 INTERSTITIALMONITORING ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION 1.ESTIMATED DATE LAST USED(MO/DAY/YR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH SUB STANCE REMAINING GALLONS INERTMATERIAL7 YES E] NO❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANTS NAME DATE I.PUD a 919.0 LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY 9 JURISDICTION 9 FACILITY 9 TANK 9 STATE LD.# `� PERMIT NUMBER PERMIT APPROVED BY/OATE PERMIT EXPIRATION DATE f-l- FORM B (1490) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. PoR06MLR1