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�. STATEOFCAUPORNIA '`•uu, STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B COMPLETE A SEPARATE FORM FOR CH TANK SYSTEM. .. MARK ONLY 1 NEW PERMIT ❑ ] RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLYOSE SITE ONE REM ❑ 2 INTERIM PERMIT F-14 AMENDED PERMIT ❑ 8 TEMPORARY TANK CLOSURE C:] B TANK REMOVE-clO DBA OR FACILITY NAME WHERE TANK IS INSTALLED: -57 S3 I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A. OWNER'S TANK L D.0 * S. MANUFACTURED BY: eg4f--/N L+ IC. DATE INSTALLED(MCA)AY/YEAR) I 0I,•�1 0. TANK CAPACITY IN GALLONS: II.TANK ONTENTS IFA-1 IS MARKED.COMPLETE ITEM C. A 1 MOTOR VEHICLE FUEL ❑ e OIL B. D 1a REGULAR ] DIESEL ❑ 8 AVIATIONGAS ❑ 2 PETROLEUM '❑ BO EMPTY ❑ 1 PRODUCT ❑ 1D PREMIUM ❑UNLEADED a GASAHOL ❑ 7 METHANOL ] CHEMICALPRODUCT E95 UNKNOWN UNLEADED 5 JETFUEL 2 WASTE ❑ 2 LEADED 99 OTHER (OESCRISE IN ITEM 0. BELOW 0. .F(Ad)IS NOT MARKEO. ENTER NAME OF SUBSTANCE STORED C.A.S.a III• TANK CONSTRUCTION MARKONE ITEMONLYIN BOXES A S.ANOC.AND ALL THAT APPLIES IN BOX A. TYPE OF ❑ 1 DOUBLE WALL ❑ ] SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM �2 51 LE WALL ❑ a SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER 1 B. TANK BARE STEEL F72 STAINLESS STEEL ] FIBERGLASS { STEELCLAO WI FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 8 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ B 100. METHANOL COMPATIBLEWIFRP (Pnma7Tank) ❑ 9 BRONZE l t0,,,��`((("""" GALVANIZED STEEL ❑ 95 UNKNOWN C:] 99 OTHER ❑ 1 RUBBER LINED KYD LINING ❑ ] EPDXY LINING ❑ A PHENOLIC LINING C.INTERIOR F75 GLASS LINING LINING a UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER I z lL C IS LINING MATERIAL CCMPATIBLe WITM 100%METHANOL? VES_ NO— D.CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 NO ❑ 0 VINYL WRAP ❑ A FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER IV.PIPING INFORMATION CIRCLE AIFA80VEGAOUNDORUIFUNDERGROUND.BOTH IFAPPUCABLE A. SYSTEM TYPE A U 1 SUCTION AW 2 PRESSURE A U ] GRAVITY A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL A U 2 DOUBLE WALL A U ] LINED TRENCH U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND A U 1 BARE STEEL A U 2 STAINLESS STEEL A U ] POLYVINYL CHLORIDE(PVC)A U a FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U a CONCRETE A U 7 STEEL WICOATING A U 8 100% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHOOIOPROTECTION 195 UNKNOWN A U 99 OTHER D. LEAK DETECTION ❑ I AUTOMATIC LINE LEAK DETECTOR ❑ 2 LNETIGHTNESSTESTING ❑ 3 KrERORMG ❑ W OTHER MONV.TANK LEAK DETECTION n ❑ 1 VISUAL CHECK 2 INVENTORY RECONCILIATION ❑ ] VAPOR MONITORING❑ a AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING i� 8 TANK TESTING ❑ 7 INTERSTITIAL MONITORING ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION 1.ESTIMATED DATE LAST USS (MO/OAV/VR) 2.ESTIMATED QUANTITY OF ].WAS TANK FILLED WITH �V SUBSTANCE REMAINING GALLONS INERTMATERIAL? YES ❑ NO❑ THIS FORM HAS BEEk COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANTS NAME DATE IPRNTEOA SK1 MRO LOCAL AGENCY USE ONLY THE STATE LD.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY x JURISDICTION x FACILITY x TANK x STi�oo' ` 0 ® O PERMITNUMBER PERMITAPPROVEO BATE rnJ/^J4 PERMIT EXPIRATION DATE FORM 8 (490) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. FOR06Y64M