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STATEOFCAUFORNIA a `i STATE WATER RESOURCES CONTROL BOARD. ' UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM B ae COMPLETE A SEPARATE FORM FOR E ANK SYSTEM MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT PK5 CHANGE OF INFORMATION ❑ 7 MANENTLY CLOSED ON ONE REM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ B TEMPORARY TANK CLOSURE B TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: /70 ,f- 13 v n (w I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A. OWNER'S TANK 1.D.# NB. MANUFACTURED BY: tjAo Y4VVLjyV -4 C. DATE INSTALLED(MO/DAY/YEAR) Vn IAj D. TANK CAPACITY IN GALLONS: OQ ILTANKCO ENTS IFA-1 IS MARKED,COMPLETE ITEM C. REGULAR 3 DIESEL ❑ A. 1 MOTOR VEHICLE FUEL 4 OIL B. C. . 6 AVIATION GAS UNLEADED 4 GASAHOL ❑ 2 PETROLEUM Q EMPTY ❑ 1 PRODUCT ❑ 1bPREMIUM H UNLEAD D ❑ 5 JETFUEL ❑ 7 METHANOL ❑ S CHEMICALPRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED ❑ 99 OTHER (DESCRIBE IN ITEM D. BELOW) D. IF IA.1)IS NOT MARKED, ENTER NAME OFSUBSTANCE STORED C.A.S.V: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A,B.AND C.AND ALL THAT APPLIES IN BOX D AND A. TYPE OF ❑,—,/i yO U'BLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM L� 2 GLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER B. TANK 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE F-� 7 ALUMINUM ❑ B 100% METHANOL COMPATIBLE W/FRP (PrimaryTank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 96 UNKNOWN E::] 99 OTHER ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING E:] 3 UXY LINING ❑ 4 PHENOLIC LINING C.INTERIOR ❑ 5 GLASS LINING ❑ 8 UNLINED 141—X/95 UNKNOWN ❑ 99 OTHER LINING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO— D.CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ NVL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION F-15 CATHODIC PROTECTION ❑ 91 NONE B5 UNKNOWN ❑ 99 OTHER '',�L/ E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) -_0 IV.PIPING INFORMATION CIRCLE A IFABOVEGROUNDOR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A ff7UCTK)N A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND A 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 CATHODICPROTECTK)N A U 95 UNKNOWN A U 99 OTH D. LEAK DETECTION ❑ 1 AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING ❑ MONOORING 99 OTHER V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VADOZE MONITORING ❑ d AUT C TANK GAUGING ❑ 5 GROUND WATER MONITORING F76 TANK TESTING [-] 7 INTERSTITIAL MONITORING E::] 91 NONE UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION 1.ESTIMATED DA LAST USE (MO/DAY/YR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH SUB STANCEREMAINING /Y�LLONS INERTMATERIAL? Eel YES O NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY AND TO THE STOFIMYKN%VLEDGE, IS TRUE AND CORRECT APPLICANTS NAME " DATE IPRINTED651GNNTURE) I LOCAL AGENCY USE ONLY THE STATE I.D.NUMAR IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY# TANK# EOP-3/7 STATE I.D.# ® = 5 7 PERMIT NUMBER PERMIT APPROVED BY/DATE y/� PERMITEXPIRATION DATE FORM B (7.91) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. FORMS R5