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t60UR t9 • STATE OF CALIFORNIA �= STATE WATER RESOURCES CONTROL BOARD sit UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B c- s , o COMPLETE ASEP TEfOAM F0�TA M MARK ONLY ❑ 1 NEW PERMIT C 3,RENEWAL PERMIT 5 CHANGE OF INF ATION P ANENTLY Ci2w SITE ONE ITEM ❑ 2 INTERIM PERMIT 4 AMENDED PERMIT ❑ 6 T MPORARV ANK C SURE 8 ANK REMOVED o ,. DBA OR FACILITY NAME WHERE TANK IS TALLED: I%1%.Jl Q.IQ, I. TANK DESCRIPTION COMPL TE ALL ITEMS- SPECIFY IF UNKNOWN A. OWNER'S TANK I.D.i 1 B. MANUFACTURED BY: V C. DATE INSTALLED(MO/DAYIVEAR) D. TANK CAPACITY IN GALLONS: sa II.TANKCONTENTS IFA-(ISMARKED,COMPLETE ITEM C. 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. / C. 1aUNLEAD REGULAR 3 DIESEL ❑ 6 AVIATIONGAS A 2 PETROLEUM ❑ 00 EMPTY XI 1 PRODUCT ❑ 10 PREMIUM 4 GASAHOL ❑ 7 METHANOL ++""11 UNLEADED ❑ 5 JETFUEL ❑ 3 CHEMICALPRODUCT ❑ 95 UNIG40WN ❑ 2 WASTE ❑ 2 LEADED ❑ 99 OTHER (DESCRIBE IN ITEM D. BELOW( 0. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S.i III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.B.AND C,AND ALL THAT APPLIES IN BOX A. TYPE OF ❑ I DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM 2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER 1 SAFE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B. TANK 6 POLYVINYL CHLORIDE 7 ALUMINUM 8 100% METHANOL COMPATIBLE W/FRP MATERIAL ❑ s CONCRETE ❑ ❑ ❑ (PrimaryTank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING C.INTERIOR ❑ 5 GLASS LINING ❑ 6 UNLINED95 UNKNOWN ❑ 99 OTHER LINING Apmaj IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? YES_ NO— D.CORROSION ❑ 1 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 IF ABOVE GROUND OR U IF UNDERGROUND.BOTH IF APPLICABLE A. SYSTEMTYPE A U I SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER KB. CONSTRUCTION A U 1 SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 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 4 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 8 CONCRETE A U 7 STEEL W/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 ❑ I AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING ❑ 3 MONRORINGL ❑ 99 OTHER .TANK LEAK DETECTION ,\ ❑ 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VAPOR MONITORING❑ 4 AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING \\�\1 ❑ 6 TANK TESTING ❑ 7 INTERSTITIALMONRORING ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION 1.ESTIMATED DATE LAST USED(MO/DAY/YR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES NO SUB ETANCEREMAINING GALLONS I INERTMATERIAL7 [:] ❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANTS NAME DATE (PANTED a SIGNATURE) p LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW v�2 COUNTY# JURISDICTION# FACILITY# TANK# STATE I.D.# I o p PERMITNUMBER L PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE FORM B (9490) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. / FOIi00718•R4