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eAo • e c STATE OF CALIFORNIA 9 STATE WATER RESOURCES CONTROL BOARD Wy v a UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B ;n o COMPLETE A SEPARATE FORM FOR EA ANK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT F-] 3 RENEWAL PERMIT EP45 CHANGE OF INFORMATION E] 7 PERMANENTLY CLOSED 4(5_ON SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ B TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: 4// ^41 I. TANK DESCRIPTION COMPLETE ALL ITEMS-- SPECIFY IF UNKNOWN A. OWNER'S TANK I.D.s B. MANUFACTURED BY: C. DATE INSTALLED(MO/DAYNEAR) D. TANK CAPACITY IN GALLONS: ILTANKCONTENTS IFA-1 IS MARKED,COMP ITEM C. I�I A ❑ 1 MOTOR VEHICLE FUEL 4 OIL B. O. ❑ 18 REGUL EO I� 3 DIESEL ❑ 6 AVIATION GAS 2 PETROLEUM 80 EMPTY ❑ RODUCT ❑ 10 PREMIUM I�—ff 4 GASAHOL ❑ 7 METHANOL ❑ ❑ 95 UNKNOWN 2 WASTE 2ULEADEDD D 99 JOTHERET L(DESCRIBE IN ITEM D. BELOW) ❑ 3 CHEMICALPRODUCT ❑ ❑ D. IF(A.1)IS NOT MARKED. ENTER NAME OF SUBSTANCE STORED C.A.S.i III. TANK CONSTRUCTION MARK ONE ITEM ONLY XES A.S.AND C,AND ALLTHAT APPLIES IN BOX A. TYPE OF ❑ 1 DOUBLE WALL 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM ❑ 2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTEDTANK) ❑ 99 OTHER ❑ 1 BARE STEEL 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEELCLAD W/FIBERGLASS REINFORCED PLASTIC B. TANK 6 POLYVINYL CHLORIDE 7 ALUMINUM 8 100% METHANOL COMPATIBLE W/FRP MATERIAL ❑ 5 CONCRETE ❑ ❑ ❑ (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ B9 OTHER ❑ 1 RUBBER LINED ❑ KYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING C.INTERIOR ❑ 5 GLASS LINING 8 UNLINED ❑ 96 UNKNOWN ❑ 90 OTHER LINING IS LINING MATERIAL COMPATIBLE WITH 10D%METHANOL? YES_ NO— D.CORROSION ❑ 1 POLYETHYLENE WRAP ❑ COATING [—] 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION F-15 CATHODIC PROTECTION 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 2 PRESSURE A U A U 99 OTHER B. CONSTRUCTION A U 1 <0GL A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND A U 1 BARE 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 STEEL W/COATING A U 8 100% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U A U 99 OTHER D. LEAK DETECTION ❑ 1 AUTOMATIC LINE LEAK DETEC-nR ❑ 2 LINE TIGHTNESS TESTING ❑ 3 MONITOR(GLF2,9rOTHER V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK 2 INVENTORY RECONCILIATION ❑ 3 VAPOR MONITORING❑ 4 AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING ❑ 6 TANK TESTING ❑ 7 INTERSTITIAL MONITORING ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION 1.ESTIMATED DATELASTUSED(MO/DAV/Vfl) 2.ESTIMATED QUANTITY OF O GALLONS 3 WAS TAN MATED WITH YES ❑ NO 3 J s/' SUBSTANCE REMAINING THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANTS NAME DATE (PAINTED a SIGNATURE) LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY# TANK# STATE I.D.# 3 FR1 7 Lid FT_F]71QL9j PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATKIN DATE FORM B (9.90) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORMA,UNLESS A CURRENT FORMA HAS BEEN FILED. ` / FOR90316-M