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STATE OF CALIFORNIA `^4• ��` STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B V C•t�.,,n,. COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY Q 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANEN ED ON T ONE ITEM ❑ 2 INTERIM PERMIT ❑ d AMENDED PERMIT ❑ 8 TEMPORARY TANK CLOSURE ❑ 8 TANK REMO D �S DBA OR FACILITY NAME WHERE TANK IS INSTALLED: S Y S• v't.T v.7�� I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A. OWNER'S TANK I.D.• B. MANUFACTURED BY: �(�L C. DATE INSTALLED(MO/DAYNEAR) K D. TANK CAPACITY IN GALLONS: 490 II.TANKC ENTS IFA-11S MARKED,COMPLETE ITEM C. A. 1 MOTOR VEHICLE FUEL Q d OIL B. C. ❑ 1i REGUL R 3 DIESEL ❑ 8 AVIATION GAS IQ 2 PETROLEUM Q W EMPTY 1 PRODUCT ❑ tb PREMIUM d GASAHOL �1 ] METHANOL UNLEADED Q 5 JET FUEL I� ❑ 3 CHEMICAL PRODUCT Q 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.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 ❑ BLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM V�NUGLE WALL ❑ d SECONDARY CONTAINMENT (VAULTED TANK) Q 99 OTHER B. TANK t BARE STEEL ❑ 2 STAINLESS STEEL 3 FIBERGLASS ❑ d STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC - MATERIAL 5 CONCRETE Q 8 POLYVINYL CHLORIDE ❑ ] ALUMINUM ❑ 8 100% METHANOL COMPATIBLE WARP (PrimaryTank) 9 BRONZE Q 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER Q 1 RUBBER LINED KYO LINING ❑ 3 EPDXY LINING ❑ d PHENOLIC LINING C.INTERIOR Q 5 GLASS LINING 8 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER LINING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES— NO_ D.CORROSION ❑ t POLYETHYLENE WRAP Q 2 ATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) IV.PIPING INFORMATION A IF ABOVEGROUND OR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 CTIO A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A U t IN L A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND A U BARE STE A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A U d FIBERGLASS PIPE CORROSION A U 5 ALU INUM A U 5 CONCRETE A U 7 STEEL WI COATING A U 8 100% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION ❑ t AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING ❑ NTLMONRSTITAL ❑ 99 OTHER V.TANK LEAK DETECTION 1 VISUAL CHECK 2 INVENTORY RECONCILIATION Q 3 VADOZE MONITORING ❑ d AUTOMATIC TANK GAUGING Q 5 GROUND WATER MONITORING 6 TANK TESTING ❑ 7 INTERSTITIAL MONITORING ❑ 91 NONE Q 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION 1.ESTIMATED DATE LAST USED(MO/DAV/YR) 2.ESTIMATED OUANTITV OF 3.WAS TANK FILLED WITH SUBSTANCE REMAINING GALLONS INERT MATERIAL 7 YES ❑ NO❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANTS NAME DATE IPgiN1E0 8 SIGNA. 0 LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY x JURISDICTION# FACILITY x TANK* CgtiJL�O)' G, STATE LDA ® = I I Ig 3 PERMITNUMBER PERMITAPPROVED BY/DA PERMIT EXPIRATION DATE FORMS (7-91) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED.