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E VR t �E C STATE OF CALIFORMA STATE WATER RESOURCES CONTROL BOARD im r UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B y o COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATIONPERMANENTLY CLOSED ON SITE ONE ITEM E] 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE �8 TANK REMOVED DBAOR FACILITY NAME WHERE TANK IS INSTALLED: oi?S /7kl A& Z'ou) ' I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A. OWNERS TANK I.D.a B. MANUFACTURED BY: N C. DATE INSTALLED(MO/DAYNEAR) p(,� D. TANK CAPACITY IN GALLONS: '�v ILTANKCONTENTS IFA-11SMARKED,COMP EMC. A ❑ 1 MOTOR VEHICLE FUEL zi 4 OIL 6. C. ❑ Ia REOUL R 8 3 DIESEL E::] 8 AVIATIONGAS F-] 2 PETROLEUM ❑ 80 EMPTY IXX'T ❑ 1bUNLEADED ❑ 5 JET FUEL 4 GASAHOL ❑ 7 METHANOL ❑ 3 CHEMICALPRODUCT ❑ 95 UNKNOWN in 2 WASTE ❑ 2 LEADED ❑ 99 OTHER (DESCRIBE IN ITEM D. BELOW) D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S.s: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.B.AND C,AND ALL THATAPPLIES IN BOX A. TYPE OF ❑ 1 UeLE WALL F-13 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM GLE WALL E:] 4 SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER B. TANK 1 BARE STEEL E] 2 STAINLESS STEEL ❑ 3 FIBERGLASS E::] 4 STEELCLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ e POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ B 100x METHANOL COMPATIBLE W/FRP (PrimaryTank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED ❑AMD LINING F-13 EPDXY LINING ❑ 4 PHENOLIC LINING C.INTERIOR F-15 GLASS LINING a UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER LINING IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL 7 YES_ NO— D.CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING [—]_,!,YWL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE 95 UNKNOWN ❑ 99 OTHER IV.PIPING INFORMATION CIRCLE A IFABOVEGROUNDOR U IF UNDERGROUND,BOTH IFAPPLICABLE A. SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A GRAVITY A U 99 OTHER B. CONSTRUCTION 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 CORROSIONA U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL W/COATING A U 8 100% METHANOL COMPATIBLE W/FRP PROTECTION U GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION ❑1 AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING ❑ 3 MONITORING ❑9B OTHER V.TANK LEAK DETECTION 1 VISUAL CHECK F-] 2 INVENTORY RECONCILIATION ❑ 3 VAPOR MONITORING❑ 4 AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING e TANK TESTING ❑ 7 INTERSTITIAL MONITORING ❑ BI NONE ❑ 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION t.ESTIMATED DATE LAS USED( MAYNFI) 2.ESTIMATED OUANTITY OF 3.WAS TANK FILLED WITH YES ❑ NO �� Q SUB STA NCE REMAINING I�GALLONS INERTMATERW.7 THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT APPLICANTS NAME DATE (PRINTED a SIGNMRE) LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY# TANK# STATE I.DA F,5-K] = I I lkllrl3 �4-v4ovv PERMITNUMBER PERMIT APPROVED BY/DATE 9E41MITlKRRATIOMDAR 3 11-71 FORM B (9-90) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. FOIIORMBAI