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.'4.i STATE OF CALIFORNIA ll/ "`g��'••• �o STATE WATER RESOURCES CONTROL BOARD t� UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM B � o COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT CHANGE OF INFORMATION O 7 PERMANENTLY CLOSED ON SITE ONE ITEM ❑ 2 INTERIM PERMIT O 4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE ❑ B TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: ZZ-7z 2 s. I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A. OWNER'S TANK I.D.• B. MANUFACTURED BY: / ellf5 4A / C. DATE INSTALLED(MO/DAY/YEAR) D. TANK CAPACITY IN GALLONS: O II.TANK CO S IFA-1 IS MARKED,COMPLETE ITEM C. A, 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C. aREGULAR UNLEADED 3 DIESEL O 6 AVIATION GAS ❑ 2 PETROLEUM ❑ 80 EMPTY 1 PRODUCT O Ib PREMIUM 4 GASAHOL ❑ 7 METHANOL ❑ ❑3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ UNLEADED 5 JET FUEL 2 WASTE ❑ 2 LEADED ❑ 99 OTHER (DESCRIBE IN ITEM D. BELOW) D. IF(A.1)IS NOT MARKED, ENTER NAME OFSUBSTANCE STORED C.A.S.is III. TANK CONSTRUCTION MARKONE ITEM ONLY IN BOXES&B,ANDC,AND ALLTHATAPPLIES INBOXD A. TYPE OF ❑ i DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTEDTANK) El99 OTHER B. TANKi BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP (PllmaryTwk) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING C.INTE NOR F-15 GLASS LINING ❑ 6 UNLINED EUNKNOWN ❑ 99 OTHER LIN IS LINING MATERIAL COMPATIBLE WITH IOD%METHANOL? YES_ NO— D.CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE �.� UNUNKNOWN ❑ 99 OTHER IV.PIPING INFORMATION CIRCLE A IFABOVE GROUND OR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION p r2 PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION AV 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 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 WIFRP PROTECTION A U 8 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A�J5 UNKNOWN A U 99 OTHER D. LEAK DETECTION 1 AUTOMAT IC LINE LEAK DETECTORLINE TIGHTNESS TESTING [:V3 3 MONRORINGL ❑ 99 OTHER V.TANK LEAK DETECTION ❑ 1 CHECK 2 INVENTORY RECONCILIATION ❑ 3 VAPOR MONITORING❑ 4 AUTOMATIC TANK GAUGING ❑ 6 GROUND WATER MONITORING 6 TANK TESTING ❑ 7 INTERSTITIAL MONITORING ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION 1.ESTIMATED DATE LAST USED(MO/DAY/YR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES ❑ NO❑ SUBSTANCE REMAINING GALLONS INERTMATERIAL7 THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANTS NAME DATE (PRINTED!SIGNATURE) LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY# TANK# I [O2Z STATE I.DA ® PERMITNUMBER PERMIT APPROVED BYIDATE PERMIT EXPIRATION DATE FORM B (990) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORM A,UNLESS A CURRENT FORM A HAS BEEN FAILED. FORS.M ten• /(i