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a � STATE OF CAIJPoRNA STATE WATER RESOURCES CONTROL BOARDUNDERGROUND STORAGE TANK PERMIT APPLICATION • FORM BCOMPLETE A SEPARATE FORM FOR ACH TANK SYSTEM. MARK ONLY 1 NEW PERMIT ❑ 7 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ONE REM ❑ 2 INTERIM PERMIT ❑ A AMENDED PERMIT ❑ 8 TEMPORARY TANK CLOSURE ❑ a TANK REMOVED Q / DBA OR FACILITY NAME WHERE TANK IS INSTALLED: 15—L( r I I ` 57 61 �S I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN 64 A. OWNER'S TANK I.0.x B. MANUFACTURED BY: .e- air; C. OATS INSTALLED(MOAJAYHEAR) 0. TANK CAPACITY IN GALLONS: 11.TANK CONTENTS IFA-I IS MARKED.COMPLETE ITEM C. All t MOTOR VEHICLE FUEL ❑ a OIL B. C. taUNLEADED 7 DIESEL ❑ 8 AVIATK7N GAS A ❑ 2 PETROLEUM ❑ 80 EMPTY 1 PRODUCT C:] tb PREMIUM U a ��L ❑ 7 METHANOL UNLEADED a S JETFUEL 7 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED o 99 OTHER (DESCRIBE IN ITEM D. BELOW) D. :F(Ary ISNOT MARKED. ENTER NAME OF SUBSTANCE STORED C.A.S.S III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.B.ANOC.ANO ALL THAT APPLIES IN BOX A. TYPE OF ❑ DOUBLE WALL ❑ 7 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM 2 INGLE WALL L! 6 SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER B. TANK 1 BARE STEEL ❑ 2 STAINLESS STEEL E] 7 FIBERGLASS ❑ a STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 8 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATISLE W/FRP (PrimaryTank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER I RUBBER LINEDE;-UN 2 AL WG ❑ ] EPDXY LINING ❑ a PHENOLIC LLI/NTNG C.INTERIOR I—! 5 MU LINING UNLINED F-1 95 UNKNOWN 99 OTHER LINING L_J ❑ IS LINING MATERIAL COMPATIBLE WITH 1(X0% METHANOL 7 YES_ NO_ D.CORROSION ❑ 1 POLYETHYLENE WRAP COATING ❑ S VINYL WRAP ❑ a FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER IV.PIPING INFORMATION CIRCLE A IFABOVE NO OR U IF UNDERGROUND.BOTH IF APPLICASLE A. SYSTEM TYPE A U 1 SUCTION U 2 PRESSURE A U 7 GRAVITY A U W OTHER S. CONSTRUCTION A U 1 SINGLE WALL A U 2 DOUBLE WALL A U S LINED TRENCH AU 95 UNKNOWN A U 90 OTHER C. MATERIAL AND A U 1 BARE STEEL A U 2 STAINLESS STEEL A U 7 POLYVINYL CHLORIDE TVC)A U a FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 8 CONCRETE A U 7 STEEL W/COATING A U B 100% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 9S UNKNOWN A U 99 OTHER D. LEAK DETECTION ❑ I AUTOMATIC LINE LEAK DETECTOR 2 LINETIGHTNESSTESTING ❑ MOKRTTA ❑ W OTHER V.TANK LEAK DETECTION / OTHER❑ e TTESTING 7 INTERST VISUAL CHECK 2 ❑ INVENTORY ITIAL MONITORING ❑ 21NONE V MONITORING a 95UNKNOWN AUTOMATIC GAUGING 99 GROUND WATER MONITORING VI.TANK CLOSURE INFORMATION 1.ESTIMATED DATE LAST USED(MOIDAY/YR) I 2.ESTIMATED QUANTITY OF 1 WAS TANK FILLED WITH SUBSTANCE REMAINING GALLONS INERT MATERIAL? YES C::] NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANTS NAME DATE Ipm.no a SIGNANRE) LOCAL AGENCY USE ONLY THE STATE I.D.NUMBERS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY ix JURISDICTION FACILITY TANKx STA oo' C) Q PERMITNUMBER PERMIT APPROVE08YIDATE o PERMIT EXPIRATONOATE FORM a 13901 THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORMA,UNLESS A CURRENT FORMA HAS BEEN FILED.