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STATEOFCAUFORNA STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION • FORM B , a n COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. T PF 5 CHANCE OF INFORMATION � T PERMANENTLY CLOSED ONS 5 ] RENEWAL PERMIT 1 EMARK ONLY I NEW PERMIT —. TEMPORARY TANK CLOSURE � d TANK REMOVED I I 1 EITEM 2 INTERIM PERMIT '� A AMENDED PERMIT —OR FACILITY NAME WHERE TANK IS INSTALLED: I. TANK DESCRIPTION COMPLETE ALL ITEMS{- SPECIFY IF UNKNOWN 3. MANUFACTURED BY: U. e A. OWNER'S TANK 1.0.x — V AJL-I— q 1 D. TANK CAPACITY IN GALLONS: /O/OOO C. DATE INSTALLED(MdDAYIYEAR) -%LILTANKCONTENTS FA-ILSMAFIKMXOMPLETEREMC. toREGULAR 1 ] DIESEL 7 a AVIATIONGAS MOTOR VEHICLE FUEL I❑ d OIL B. C. NLEAOED I� A GASAHOL I METHANOL CPN ' PRODUCT IPREMKIM 5 ;ET FLEL PETROLEUM J❑ � 1m11WWN ❑ 2 WASTE ❑ 2 LEADED 90 OTHER (DESCRIBE IN ITEM 0. BELOWI] CHEMICAL PRODUCT(A.1)IS NOT MARKED. ENTER NAME OF SUBSTANCE STORED III. 00X0 U TANK CONSTRUCTION MAWONE REM ONLY IN80XESA.B.ANDC.ANDALLTHATAPPLIESINZ3 • aI oouBLE WALL ] SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN A. TYPE OFI I A SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER SYSTEM !�2 SINGLE WALL .I 2 STAINLESS STEEL — ] FIBERGLASS ❑ A STEEL CUD VII FIBERGLASS REINFORCED PLASTIC J I BARE STEM -- g. TANK �. 5 CONCRETE �'❑ S 20lWNYL CHLORIDE ❑ T ALUMINUM S t00x METHANOL COMPATIBLE WIFRP MATERIAL 19 GALVANIZED STEEL —' UNKNOWN I 99 OTHER IPHmwy Tank) I 9 BRONZE 1 RUBBER LINED AUC/D LINING —' ] 30XY '-.NNG i PHENOLIC LINING C.INTERIOR '1 5 GLA55 IJNWG UNUM® 96 UNKNOWN ❑ w OTHER LINING - IS LINING MATERIAL COMPATIBLE WITH 10011•METHANOL' YES— '� 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ ] TM1VL WRAP ❑ a FBERGLASS REWFORC'cD FUSTIC O.CORROSION a 9T NONE 96 UNKNOWN ❑ 99 OTHER PROTECTION I❑ 5 CATHODKI PROTECTION — IV.PIPING INFORMATION CIRCLE A IFABOVEGROUNDOR U IFUNDERGROUNO.30THIFAPPL:CASLE A. SYSTEM TYPE A U 1 SUCTION AIVPRESSURE A U ] GRAVITY A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE 'NALL A U 2 DOUBLE WALL A Ck LINED TRENCH A U 95 UNKNOWN A U 99 OTHER A U I BARE STEEL A U 2 STAINLESS STEEL A U ] POLYVINYL CHLORIDE(PVC)Aa7A FIBERGLASS PIPE C. MATERIAL AND A U 6 CONCRETE A U T STFcL 1'a C'7• GATINA U B I00% METHANOL COMPATIBLEWIF IAP CORROSION A U 5 ALUMINUM PROTECTION A U 9 GALVANIZED STEM A U 10 CATHOOOPROT'cCT1ON A U 96 UNKNOWN A U X99—(OTHER D. LEAK DETECTION ❑ I AUTOMATIC UNE LEAK OETECTOR 2 LINETIGHTNESSTESTING �! 3 VONROPWG ❑92 OTHER V.TANK LEAK DETECTION !❑ t UAL CHECK 2 INVENTORY RECONCILIATION '^ 3 VAPOR MONITORING 1— A AUTOMATIC TANK GAUGING 5 GROLNO WATER MONITORING r 6 TANK TESTING ❑ T INTERSTRIAL MONTT10R9VG 91 ^LONE 35 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION LL WAS TANK FILLED WITH STMATED DATE LAST USED GALLONS (MOIOAVIVR) I i ESTIMATED OUANTTY CF INERT MATERIAL? YES ❑ '� t.e SUBSTANCE REMAINING THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGGF-IS TRUE AND CORRECT DATE APPLICANTS NAME I%yNM IT SWNANRS LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW CTOUNTY x JURISDICTION x FACILITY At TANK x 00 �S 7� STATE I.D.n PERMIT NUMBER PERMIT APPROVED BY/DATE I PERMITS 'TtATK9N DATE FoRM B (9.8 ) THIS FORM MUST BE ACCOMPANIED BY A PERMR APPLICATION-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. kF 6RA ` 64- 1w15 y Irrl