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• • ace STATE OF CALIFORNIA � STATE WATER RESOURCES CONTROL BOARD a.,� !" u S UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B •OP M� COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. - ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7/ ENTLY CLOSED Qb6SaTF MARK ONLY E:] 1 NEW PERMIT ❑ -� ONE ITEM E] 2 INTERIM PERMIT F74 AMENDED PERMIT 8 TEMPORARY TANK CLOSURE �( a TANK REMOVED r d P _ 5 -ov Nils. ol '_ DBA OR FACILITY NAME WHERE TANK IS INS] 11�. P ALLED: � !�p _�-� I/� eU� (YI Arlw}2.fio-- ( C�19 I. TANK DESCRIPTION COMPLETE ALL ITEMS-- SPECIFY IF UNKNOWN B. MANUFACTURED BV: Uz A. OWNER'S TANK LO.# u� - _ G D. TANK CAPACITY IN GALLONS: C. DATE INSTALLED(MO/DAY/YEAR) II.TANK CONTENTS IFA-11SMARKED,COMPLETE ITEM C. aREGULAR lu 3 DIESEL ❑ 6 AVIATIONGAS A 1 MOTOR VEHICLE FUEL 4 OIL B. C• ❑ UNLEADED 4 GASAHOL ❑ 7 METHANOL 2 PETROLEUM ❑ 80 EMPTY 1 PflODUCT ❑ 1bUNLEADED PREMIUM ❑ 5 JET FUEL [:j95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED ❑ 99 OTHER (DESCRIBE IN ITEM D. BELOW) El 3 CHEMICAL PRODUCT D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A,S,AND C,AND ALLTHAT APPLIES IN BOX D AND ❑ 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN rMATERIAL E OF ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER TEM z SINGLE WALL 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEELCLAD W/FIBERGLASS REINFORCED PLASTIC NK ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ B 100% METHANOL COMPATISLEW LE W/FRP 5 CONCRETE ry Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING C.INTERIOR ❑ 6 GLASS LINING ®- 6 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER LINING IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? YES_ NO_ POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC D.CORROSION El 1 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 CIRCLE AIFABOVE GROUND ORUIFUNDERGROU ,BOTHIFAPPLICABLE A. SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION 1 SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND U 1 BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A U 4 FIBERGLASS PIPE CORROSION A 5 ALUMINUM p U 6 CONCRETE p U 7 STEEL W/COATING A U 6 100% 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 ❑ 1 AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING ❑ MONITORING ❑ 99 OTHER V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VADOZE MONITORING ❑ 4 AUTOMATIC TANK GAUGING ❑ 5 GROUNDWATER MONITORING ❑ 6 TANK TESTING ❑ 7 INTERSTITIAL MONITORING >fl 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES ❑ NO r 1.ESTIf,� .DJDATE LAST USED(MOIDAV/VR) SUBSTANCE REMAINING GALLONS INERT MATERIAL? THIS FORM HAS BEEN COMPLETED UNDER PENA OF PERJURY,AND TO THE(BEST OF MY KNOWLEDCGEE I�Sj TRUE AND CORRECT APPLICANTS NAME NC� (PNNTEDb SIGNATURE) C I LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY# I � TANK# STATE I.D.# FTI = I I � PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE FORM 8 (7-91) THIS FORM MUST BE AC%MP I �PE_Mi KATION-FORMA,UNLESS A CURT FORMA HAS BEEN FILED. FOR99�48