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*40oI STATE OF CALIFORNIA + - / STATE WATER RESOURCES CONTROL BOARD ff UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM B �s 'e COMPLETE A SEPARATE F M FOR TANK SYSTEM MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 ANGE OF INFORMATION ❑ 7 PERMAN Y CLOSE ONE ITEM ❑ 2 INTERIM PERMIT ❑ A AMENDED PERMIT TEMPORARY TANK CLOSURE ❑ 8 TANK RE OVED Vo DBA OR FACILITY NAME WHERE TANK IS INSTALLED: O a W I IRU , I. TANK DESCRIPTION COMPLETE ALL ITEMS— SPECIFY IF UNKNOWN A. OWNER'S TANK I.D.# v B. MANUFACTURED BY: C. DATE INSTALLED(MOfDAYNEAR) D. TANK CAPACITY IN GALLONS: II.TANK CONTENTS IFA-1 IS MARKED,COMPLETE ITEMC. A. F-1i MOTOR VEHICLE FUEL I OIL B. C. ❑ 18UNLGEADED ULAR 3 DIESEL ❑ 8 AVIATKNGAS ❑ 2 PETROLEUM ❑ 80 EMPTY ❑ 1 PRODUCT ❑ 1b PREMIUM A GASAtKIL ❑ 7 METHANOL UNLEADED 5 JET FUEL ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN E::] 2 WASTE ❑ 2 LEADED 99 OTHER (DESCRIBE IN ITEM D. BELOW) D. IF(A.1)0 NOT MARKED, ENTER NAME OF SUBSTANCE STORED r C.A.S.s: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.B.AND C,AND ALL THAT APPLIES BOXD A. TYPE OF ❑ 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER 95 UNKNOWN SYSTEM ❑ 2 SINGLE WALL ❑ s SECONDARY CONTAINMENT (VAULTED TANK) ❑ 90 OTHER B. TANK ❑ 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ a STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 0 POLYVINYL CHLORIDE ❑ 7 MINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP (PrimaryTank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL UNKNOWN 99 OTHER ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 OXY LINING ❑ ♦ PHENOLIC LINING C.INTERIOR ❑ 5 GLASS LINING ❑ 8 UNLINED 95 UNKNOWN ❑ N OTHER LINING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL 7 YES_ NO— D.CORROSION ❑ 1 POLYETHYLENE WRAP [:] 2 COATING ❑ 3 VINYL WRAP ❑ a FIBERGLASS REINFORCED PLASTIC 41 PROTECTION E:] 5 CATHODIC PROTECTION a 91 NONE UNKNOWN ❑ 99 OTHER IV,PIPING INFORMATION CIRCLE A IFABOVEGROUNOOR U IF UNDERGROUND,BOTH IF APPLICABLE A SYSTEM TYPE A U I SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A U I SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND A U I BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A U a FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U e CONCRETE A U 7 STEEL WI COATING A U 8 100% METHANOL COMPATIBLE W/FRP 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 ❑ MTEASIT A ❑ OTHER V.TANK LEAK DETECTION ` ❑ 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VAPOR MONITORING❑ 0 AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING I`UN\ ❑ 8 TANK TESTING ❑ 7 INTERSTITIAL MONITORING ❑ 91 NONE ❑ 95 UNKNOWN ❑ W OTHER VI.TANK CLOSURE INFORMATION 1.ESTIMATED DATE LAST USED(MO/DAYNR) 2.ESTIMATED OUANTITY OF 3.WAS TANK FILLED WITH YES ❑ NO❑ SUBSTANCE REMAINING GALLONS NERTMATERIAL? THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE IS TRUE AND CORRECT APPLICANT'S NAME DATE /J ry (PRINTED d SIGMTUREI / 1 Q LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW GJ l COUNTY# JURISDICTION# FACILITY# TANK* STATE I.D.# 0 10111 gi p d 16 loll0 PERMIT NUMBERrt PERMIT APPROVED BY/DAT PERMIT EXPIRATION DATE i: FORMS (&I)M THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. FOR043 U (7 / z . ��