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STATEOFCALIFORMA STATE WATER RESOURCES CONTROL BOARD s UNDERGROUND STORAGE TANK PERMIT APPLICATION" FORM B " COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLO ONE ITEM ❑ 2 INTERIM PERMIT F-1 4 AMENDED PERMIT ❑ 9 TEMPORARY TANK CLOSURE [:] 9 TANK REMOVED / 4 Y DSA OR FACILITY NAME WHERE TANK IS INSTALLED6bc lt% AL3{> -1-eiewroV *1411-5 Aft 5b_sD r&J�a9 I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A. OWNER'S TANK I.D.• V ov-woi.ALjL/ B. MANUFACTURED BY: iV L Gjy%TA41..JNE/-+T C. DATE INSTALLED(MOIDAY/YEAR) -1 D. TANK CAPACITY IN GALLONS: 000 ILTANKCONTENTS IFMA ISMARKEO,COMPLETE ITEM C. A. ❑ ❑ 14REGULAR S AVIATION GAS UNLEADED 3 DIESEL ❑ 1 MOTOR VEHICLE FUEL 4 OIL B. C. ❑ 2 PETROLEUM ❑ 90 EMPTY 1 PgODl1CT 1A PREMIUM A GASAHOL ❑ 7 METHANOL UNLEADED 5 JETFUEL ❑ 3 CHEMICALPRODUCT ❑ 95 UNKNOWN ❑ 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.I: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.B.AND C.AND ALL THAT APPLIES IN BOX D AND A. TYPE OF 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ % UNKNOWN SYSTEM 2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER S. TANK ❑ 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS lI* 4 STEELCLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ e POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ B 100% METHANOL COMPATIBLE W/FRP (P6mAr7TAnk) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING C.INTERIOR ❑ 5 GLASS LINING9 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER LINING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO_ D.CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE �ql�� E:]95 UNKNOWN 99 OTHER E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR) 119 " OVERFILL PREVENTK)NEWIPMENTINSTALLED(YEAR) IV.PIPING INFORMATION CIRCLE A IFABOVEGROUNDOR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION A 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL I 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U oD OTHER C. MATERIAL AND A U 1 BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A4 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U B CONCRETE A U 7 STEEL W/COATING A U B 100% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTON A U W UNKNOWN A U M OTHER D. LEAK DETECTION ❑ 1 AUTOMATIC LINE LEAK DETEcroR 2 LINE TIGHTNESS TESTING MONITORING ❑99 OTHER V.TANK LEAK DETECTION VISUAL CHECK ry/2 INVENTORY RECONCILIATION ❑ 3 VADOZE MONITORING 4 AUTOMATE TANK GAUGING ❑ 5 GROUND WATER MONITORING F,K. TANK TESTING u ' 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 INERTMATERIAL? THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANTS NAME I Aat 1Pmx1c9aswNAruraEYf71Gk #A CC A01 ��. ..41 I MIC. DATEl 14 �-7 LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR N BELOW COUNTY R JURISDICTION K FACIL N TANK N STATE I.D.# p /,16-1 PERMIT NUMBER PERMIT APPROVED BY/OATE PERMIT E%PIRATON DATE THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORMA,UNLESS A CURRENT FORMA HAS BEEN FILED. FILE THIS FORM WITH TH'"1CAL AGENCY IMPLEMENTING THE UNDERGROUND STOF -TANK REGULATIONS 3_C]rl FORM B (1291) 1 �. '".001 G, FORMBAS