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�souP e STATE OF CALIFORNIA ae a STATE WATER RESOURCES CONTROL BOARD i - UNDERGROUND STORAGE TANK PERMIT APPLICATION • FORM B o � vj COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENT)f 5PSED ON S ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 9 TANK REM V DBA OR FACILITY NAME WHERE TANK IS INSTALLED: ?-614 2-?- !V . E fG I. TANK DESCRIPTION COMPLETE ALL ITEMS-- SPECIFY IF UNKNOWN A. OWNER'S TANK I.D.t v, B. MANUFACTURED BY: IJ' k C. DATE INSTALLED(MO/DAY/YEAR) L1 . 9 . D. TANK CAPACITY IN GALLONS: II.TANK CONTENTS IFA-1 ISMARKEDODMPLETEITEM C. n 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C. ❑ 1eUNLEAOED 6 DA GSAHOL SEL ❑ e AVIATION GAS A O 2 PETROLEUM ❑ BO EMPTY t PRODUCT ❑ lb P-VKLREMIUM [::] 5 JET FUEL ❑ 7 METHANOL ❑ 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.0: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A B.AND C.AND ALL THAT APPLIES IN BOXD 95 A. TYPE OF ❑ 1 DOUBLE WALL [:] 3 SINGLE WALL WITH EXTERIOR LINER UNKNOWN SYSTEM ❑ 2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTEDTANK) ❑ 99 OTHER ❑ 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B. TANK ❑ 6 POLYVINYL CHLORIDE ALUMINUM 8 10096 METHANOL COMPATIBLE W/FRP MATERIAL ❑ s CONCRETE ❑ (PrimaryTmk) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL 96 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING EPDXY LINING ❑ 4 PHENOLIC LINING C.INTERIOR ❑ 5 GLASS LINING ❑ 8 UNLINED 95 UNKNOWN ❑ 99 OTHER - LINING I6 LINING MATERIAL COMPATIBLE WITH 100%METHANOL? YES_ NO— D.CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ WNYL 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 IF APPLICABLE A. SYSTEM TYPE ey/ SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A U / SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH UNKNOWN A V 99 OTHER C. MATERIAL AND A U 1 BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A U 4 F18ERGLASS PIPE CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U7 ST COATING A U 8 100% METHANOL COMPATIBLE WIFRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION U UNKNOWN A U 99 OTHER D. LEAK DETECTION Lj 1 AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING ❑ 16�10NRORINOL ❑ 99 OTHER V.TANK LEAK DETECTION 1 VISUAL CHECK 2 INVENTORY RECONCILIATION ❑ 3 VAPOR MONITORING AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING ❑ 6 TANK TESTING ❑ 7 INTERSTITIAL MONITORING ❑ 91 NONE KI 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION 1.ESTIMATED DATE LAST USED(MO/GAY/YR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES ❑ NO❑ SUBSTANCE REMAINING GALLONS INERT MATERIALS THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANTS NAME DATE (WLNTED 8 SIGNATURE) LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# TANK# STATE I.D.# U U loll PERMIT NUMBER PERMIT APPROVED BYIDATE ERMIT EXPIRATION DATE FORM 9 (9-9D) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. FORMIMMV,./)