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^A.00+ y STATE OF CALIFORNIA -� `' STATE WATER RESOURCES CONTROL BOARD sy 9 UNDERGROUND STORAGE TANK PERMIT APPLICATION• FORM B °�� ° 0 COMPLETE A SEPARATE FORM FOR EA H TANK SYSTEM ��""O""�� MARK ONLY 1 EW PERMIT ❑ 3 RENEWAL PERMIT $ CHANGE OF INFORMATION ❑ 7 PERMANENTLY ITE n ONE ITEM INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ B TANK REMOV I DBA OR FACILITY NAME WHERE TANK IS INSTALLED: //ST Arljl} p J I. TANK DESCRIPTION COMPLETE ALL ITEMS-SPECIFY IF UNKNOWN A OWNERS TANK I.D.0 S. MANUFACTURED BY: a �N C. DATE INSTALLED(MOCAYNEAR) D. TANK CAPACITY IN GALLONS: II.TANK q6NTENTS IFA-1 IS MARKED.COMPLETE ITEM C. to REGULAR 3 DIESEL A. 1 MOTOR VEHICLE FUEL ❑ t O0. 8. C ❑ UNLEADED ❑ 8 AVIATION GAS F-12 PETROLEUM 80 EMPTY 1 PRODUCT Ib PREMIUM 4 GASAHOL 7 METHANOL UNLEADED 5 JETFUEL ❑ ❑ 3 CHEMICALPRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED W OTHER (DESCRIBE IN ITEM D. RELOW) D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A S.4: 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 V NGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER S. TANK 02/', BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CUD WI FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE WIFRP (PrimaryTank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN 99 OTHER ❑ 1 RUBBER LINED ❑�D LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINI C.INTERIOR ❑ 5 GLASS LINING 6 UNLINED ❑ 96 UNKNOWN 99 OTHER LINING IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? YES_ NO_ PT D.CORROSION F7 POLYETHYLENE WRAP 1:1/1 I yCWTING ❑ 3 VINYL WRAC ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION LZ 91 NONE ❑95 UNKNOWN Q 99 OTHER IV.PIPING INFORMATION CIRCLE A IFABOVEOROUNDOR U IF UNDERGROUND.BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION A U RESSURE A U 3 GRAVITY A U 90 OTHER B. CONSTRUCTION A U 1 SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A 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 6 CONCRETE A U 7 ST W/COAHNG A U 8 100% METHANOL COMPATIBLE WIFRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODK:PROTECTION U 5 UNKNOWN A U 99 OTHER 0. LEAK DETECTION ❑ 1 AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINET%NHTNESS TESTING ❑ 3 WTN STI IA ❑99 OTHER V.TANK LEAK DETECTION / ❑ 1 VISUAL CHECK 2 INVENTORY RECONCILIATION ❑ 3 VAPOR MONITORING❑ 4 AUTOMATIC TANK GAUGING❑ 5 GROUND WATER MONITORING L 6 TANK TESTING ❑ 7 INTERSTITIAL MONITORING ❑ 91 NONE ❑ W UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION 1.ESTIMATED DATE LAST USED(MOIDAWYR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES ❑ 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 IPPINTfO!SIGNAIUFEI LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY 9 JURISDICTION x FACILRY x 4 TANK tl ou STATEI.D.# ® o PERMIT NUMB R PERMIT APP VED B)IDAT Cti PERMIT E%PIRATION DATE S- 2. FORM B (490) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED.