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yOV9 •y ! �O STATE OF CALIFORNIA :` y STATE WATER RESOURCES CONTROL BOARD W . i c UNDERGROUND STORAGE TANK PERMIT APPLICATION • FORM B ey .<. a COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ON SITE MARK ONLY ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED '- ONE ITEM F-12 INTERIM PERMIT ❑ 1J DBA OR FACILITY NAME WHERE TANK IS INSTALLED: '�j _ I. TANK DESCRIPTION COMPLETE ALL ITEMS— SPECIFY IF UNKNOWN /' 0. OWNER'S TANK 1.0.8 0 S. MANUFACTURED BY: v, C. DATE INSTALLED(MOIDAYA'EARI D. TANK CAPACITY 9V GALLONS: 174 ILTANKCONTENTS IFA-I ISMARKED.COMPLETE ITEM C. A ❑ 1 MOTOR VEHICLE FUEL 4OIL B. C• ❑ 1aU REGULAR 6 DIESEL GASAHL ❑ 8 AVIATION GAS F-1 2 PETROLEUM ❑ SO EMPTY PRODUCT 1:PREMIUUNLEADED 5 JET FUEL ❑ 7 METHANOL ❑ 3 CHEMX-.ALPRODLXOT F-195 UNKNOWN U WASTE ❑ 2 LEADED H 99 OTHER (DESCRIBE IN ITEM D. BELOW) O. IF(Al)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S.# III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A B.ANO C.AND ALL THAT APPLIES IN BOX ❑ 1 BLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN A. TYPE OF ❑ SYSTEM NGLE WALL a SECONDARY CONTAINMENT (VAULTED TANp ❑ 99 OTHER 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B. TANK ❑ s POLYVINYL CHLORIDE ❑ 7 ALUMINUM E:] 8 100% METHANOL COMPATIBLE W/FRP MATERIAL ❑ 5 CONCRETE (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 96 UNKNOWN ❑ 99 OTHER F-1 1 RUBBER LINED g 3 EPDXY LINING 4 PHENOLIC LINING ❑�/a ALKYD LINING ❑ C.INTERIOR ❑ 5 GLASS LINING LJ ' UNLINED ❑ 95 UNKNOWN ❑ 00 OTHER LINING L4 LINING MATERIAL COMPATIBLE WITH 100%METHANOL? YES y_�RNNO_ D.CORROSION ❑ I POLYETHYLENE WRAP ❑ 2 COATING ❑/ WRAP ❑ 4 FIBERGLASS REINFORCED PLASTC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE 95 UNKNOWN ❑ 99 OTHER IV.PIPING INFORMATION CIRCLE A IFABOVEGROUNDOR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION A U 2PRESSURE A(S) GRAVITY A U 99 OTHER S. CONSTRUCTION A&71 SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER A I BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A U A FIBERGLASS PIPE C. MATERIAL AND CORROSION A U 5 ALUMINUM A U 8 CONCRETE A U 7 STEEL WI COATING A U 8 100% METHANOL COMPATIBLE WIFRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTXON A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION ❑ I AUTOMATIC LINELEAKOETECTOR O 2 LINE TIGHTNESS TESTING ❑ 3 KIERORING 99 OTHER IJ V.TANK LEAK DETECTION ❑ I VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VAPOR MONITORINGy/Al1TOMATIC TANK GAUGING❑ 5 GROUND WATER MONITORING ❑ 6 TANK TESTING ❑ 7 89TERSTITIALMOWTORING ❑ 91 NONE r95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION 1.ESTIMATED DATE LAST USED(MOADAY/YR) 2.ESTIMATED T'OF 3.WAS TANK FILLED WITH YES ❑ ❑ REMAINING 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 (PRNTED 831GNATJM) LOCAL AGENCY USE ONLY THE STATE I.D.N UMBER IS COMPOS ED 0 F THE FOUR NU MBERS B ELOW COUNTY* JURISDICTION# FACILITY# TANK# STATE I.D.# ? �3 PERMIT NUMBER PERMIT APPROVED BYIDATE PERMIT EXPIRATION DATE FORMS (9 90) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLIcAjInON•F M A,UNLESS A CURRENT FORM A HAS BEEN FILLED. L FawmrBm