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eo Yw e STATE OF CALIFORNIA • �. ct STATE WATER RESOURCES CONTROL BOARD ; ., '; UNDERGROUND STORAGE TANK PERMIT APPLICATION • FORM B "�� ° ao COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM �""°""�� MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION 7 RMANENTLY CLOSED ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 9 TEMPORARY TANK CLOSURE 8 TANK REMOVED Q DBA OR FACILITY NAME WHERE TANK IS INSTALLED: q7 ��, ,(, va-1 I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A. OWNERS TANK 1.0.8 y B. MANUFACTURED BY: C. DATE INSTALLED(MOIDAY/YEAR) v D. TANK CAPACITY IN GALLONS: [I.TANK CONTENTS IFA•1ISMARKED.COMPLETE ITEM C. A. G' 1a REGULAR 3 DIESEL I MOTOR VEHICLE FUEL ❑ 4 OIL B. C. ❑ UNLEADED ❑ e AVIATION GAS d GASAHOL ❑ 2 PETROLEUM ❑ 80 EMPTY.10 ❑ 1 PROWCT ❑ Ib UPMIUM LEADED ❑ 5 JET FUEL ❑ ] METHANOL E] 3 CHEMICALPRODUCT 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.s: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.8•AND C.AND ALL THAT APPLIES IN BOX A. TYPE OF ❑ 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER 95 UNKNOWN SYSTEM ❑ 2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTEDTANK) ❑ 99 OTHER B. TANK ❑ I BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 8 POLYVINYL CHLORIDE 7 AlUMINUM ❑ 8 100% METHANOL COMPATIBLE WFRP (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL 95 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED ❑ 2 ALKYD LINWGn 3 EPDXY LINING ❑ 4 PHENOLIC LINING C.INTERIOR ❑ 5 GLASS LINING ❑ 8 UNLINED LINING L /98'UNKNOWN ❑ 99 OTHER IS LINING MATERIA COMPATIBLE WITH 100% METHANOL T YES— NO— D.CORROSION ❑ I POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL 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 A U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY U,y9 OTHER B. CONSTRUCTION A U I SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH p UNKNOWN A U 99 OTHER C. MATERIAL AND A U I BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A U d FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U B CONCRETE A U 7 ST W/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 ❑ I AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING ❑ 3 NTERTITLAL [:] 99 OTHER MONORING V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 7 VAPOR MONITORING❑ 4 AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING ❑ 8 TANK TESTING ❑ 7 INTERSTITUIL MONITORING 91 NON ❑ 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION 1.ESTIMATE GATE TLS$ USEf.1�,Mgl{,1AY/YR) 2. TANKFILLE SU ST NO REMA11 NGTY F GALLONS 3.WASNERT MATERIALIIH YES ❑ N THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANTS NAME DATE IPFIMED891GNATUP� LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILI TANK# STATE I.D.# � O PERMIT NUMBER PERMIT APPROVED SY/DATE PERMIT EXPIRATION DATE FORM B (9-9q THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. 7-J5—VI FOMMS-Rt 0