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STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B / . C./ COMPLETE A SEPARATE FORM FORE TANK SYSTEM, MARK ONLY ❑ 1 NEW PERMIT ❑ ] RENEWAL PERMIT S CHANGE OF INFORMATION ❑ ) PERMANENTLY/ S, ONE REM ❑ 2 INTERIM PERMIT ❑ a AMENDED PERMIT ❑ 6 TEMPORARY TANK CLCSURE ❑ 8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS MSTALLEO: Q elk a / I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A. OWNER'S TANK 1,0./ B. MANUFACTURED BY: G DATE INSTALL (M=AYNEAR) I D. TANK CAPACITY IN GALLON 11.TANK C ENTS IFa•IISUARKED.COMPLETEITEMC. A. 1 MOTOR VEHICLE FUEL ❑ a 04 9, 6 a REGULAR ] DIESEL ❑ 8 AVIATION GAS UNLEADED A GASAHOL 2 PETROLEUM ❑ 60 UNKNMPTYOWN 1 PRODUCT ❑ tOPREMIUM UNLEADED S JET FUEL ❑ 7 METHANOL ❑ ] CHEMICAL PRODUCT ❑ 9S UNKNOWN ❑ 2 WASTE ❑ 2 LEADED 8 99 OTHER (DESCRIBE W ITEM 0. BELOW) G. IF(A.I)IS NOT MARKED. ENTER NAME OF SUBSTANCE STORED C.A.S /: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.B.AND C.AND ALL THAT APPLIES IN SOX A. TYPE OF ❑ I DOUBLE WALL ❑ ] SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM ❑ 2 SINGLE WALL ❑ A SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER B. TANK ❑ I BARE STEEL ❑ 2 STAINLESS STEEL ❑ ] FIBERGLASS ❑ A STE-ELCLAn WIP18EAGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 8 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL CCMPATMLE W/FRP (Primary Tank) ❑ 9 8RON2E ❑ 10 GALVANIZED STEEL ❑ 95 UNK40WN ❑ N OTHER F-11 RUBBER LINED ❑ 2 ALI(YO LINING ] 'EPDXY LINING ❑ a PHENOLIC LINING C.I UNINGR ❑ S GLASS LINING ❑ 6 UNLINED ❑ 95 UNKNOWN ❑ 94 OTHER IS UNING MATERIAL COMPATIBLE WITH 100%METHANOL 7 YES_ NO_ 0.CORROSION F1 T POLYETHYLENE WRAP ❑ 2 COATING E] ] VINYL WRAP ❑ A FIBERGLASS REINFORCED PLASTIC PROTECTION F7 CATHCOKC PROTECTION C:] 91 NONE 95 UNXNIOWN C:] 99 OTHER IV.PIPING INFORMATION CIRCLE A IFABOvEGRCUNOOR U!FuNCERGROUN0.30THIFAPP.IcABLE A. SYSTEM TYPE A U I SUCTION A U 2 PRESSURE A U ] GRAVITY A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL A U 2 DOUBLE WALL A U ] LINED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND A V I BARE STEEL A U 2 STAINLESS STEEL A U ] POLYVINYL CHLORIDE(PVC)A U A FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL W/COATWG A U 6 100% METHANCL COMPATIBLE W/FRP PROTECTION A U 9 GALVANrMO STEEL A U 10 CAT14COICPROTECTICN A V 95 UNKLNOWN A U N OTHER D. LEAK DETECTION ❑ 1 AUTOMATIC LINE LEAK OE,ECTOR ❑ 2 LINE TIGHTNESS TESTING ❑ 3 H ' YL ❑ 99 OTHER YCNITCAPIG V.TANK LEAK DETECTION ❑ I VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 0 VAPOR MONITORING a AUTOMATIC TANK GAUGING ❑ S GROUND WATERMCNRCRWG ❑ 6 TANK TESTING ❑ 7 INTERSTI IALMONFTORING 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION 1.BE nMATEO DATE LAST USED(MCMAY/YR) IL ESTIMATED CUANTITY OF 1 WAS TANK FILED WITH SUBSTANCE REMAINING GALLONS WERTMATERIAL7 YES F-1 NO❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE. IS TRUE AND CORRECT APPLIGNTS NAME GATE 1/PI.ITFO{SIGNANPfl LOCAL AGENCY USE ONLY--THE STATE LD.NUMBER IS COMPOSED OF THE FOUR NUMBEaS BELOW �j QUNTY 6 JURISDICTION i FACILITYTANK 9 STATE LD. � �m 6 d PEAMITNUMBER :7I,PERMIT APPROVED 9vNATE I PERMIT EXPIRATICN CATE FORMS (490 THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. F01190a6Ra