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aSTATE OF CAU FORMA ...STATE WATER RESOURCES CONTROL BOARDUNDERGROUND STORAGE TANK PERMIT APPLICATION • FORM BCOMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. <br /> MARK ONLY O 1 NEW PERMIT 0 3 RENEWAL PERMIT O 5 CHANGE OF INFORMATION O 77 PERMANENTLY CLOSED ONSITE <br /> ONE ITEM 0 2 INTERIM PERMIT O 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE n--g TANK REMOVED <br /> DBA OR FACILITY NAME WHERE TANK IS INSTALLED: A Gpa 7' <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS– SPECIFY IF UNKNOWN <br /> A. OWNER'S TANK I.D.# LP B. MANUFACTURED BY: i , <br /> C. DATE INSTALLED(MO/DAYIYEAR) ` K D. TANK CAPACITY IN GALLONS: �q^JC7 <br /> ILTANKCONMENTS FAT IS MARKED.COMPLETE ITEM C. <br /> 1 MOTOR VEHICLE FUEL 4 OIL e, C 1a REGULAR 3 DIESEL <br /> A. O UNLEADED q GASOHOL O e AVIATIONGAS <br /> O 2 PETROLEUM 80 EMPTY 1 PRODUCT O lbPREMIUM <br /> UNLEAO 5 JETFUEL O 7 METHANOL <br /> O 3 CHEMICAL PRODUCT O 95 UNKNOWN O 2 WASTE O 2 LEADED O 99 OTHER (DESCRIBE IN ITEM D. BELOW) <br /> D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S.0: <br /> III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES B,AND C,AND ALL THAT APPLIES IN BOXD <br /> A. TYPE OF O 1 DOUBLE WALL 0 3 SINGLE WALL WITH EXTERIOR LINER 95 UNKNOWN <br /> SYSTEM F-1 2 SINGLE WALL 0 4 SECONDARY CONTAINMENT (VAULTEDTANK) O 99 OTHER <br /> B. TANK 1 BARE STEEL 0 2 STAINLESS STEEL O 3 FIBERGLASS 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC <br /> MATERIAL 5 CONCRETE 6 POLYVINYL CHLORIDE UMINUM 8 100% METHANOL COMPATI8LE W/FRP <br /> (PdmaryTw*) O 9 BRONZE 10 GALVANIZED STEEL 95 UNKNOWN O 99 OTHER <br /> O 1 RUBBER LINED O 2 ALKYD LINING PDXY LINING 4 PHENOLIC LINING <br /> C.INTERIOR O 5 GLASS LINING O 6 UNLINED 96 UNIONOWN 99 OTHER <br /> LINING <br /> IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO— <br /> D.CORROSION 1 POLYETHYLENE WRAP O 2 COATING VINYL WRAP O 4 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION 0 5 CATHODIC PROTECTION 0 91 NONE O 95 UNW40WN 0 99 OTHER <br /> IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND,BOTH IF APPLICABLE <br /> A. SYSTEM TYPE A 0 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER <br /> B. CONSTRUCTION A U 1 SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH 5 UNKNOWN A U 99 OTHER <br /> C. MATERIAL AND A U 1 BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A U 4 FIBERGLASS PIPE <br /> CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL W/COATING A U 8 100% METHANOL COMPATIBLE W/FRP <br /> PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION UNKNOWN A U 99 OTHER <br /> D. LEAK DETECTION [::] 1 AUTOMATIC LINE LEAK DETECTOR 0 2 LINE TIGHTNESS TESTING Q 3 INTERSTITIAL MONRORING 0 99 OTHER <br /> V.TANK LEAK DETECTION <br /> 1 VISUAL CHECK O 2 INVENTORY RECONCILIATION ❑ 3 VAPOR MONITORING 4 AUTOMATIC TANK GAUGING O 5 GROUND WATER MONITORING <br /> 6 TANK TESTING [:j 7 INTERSTITIAL MONITORING O 91 NONE O 96 UNKNOWN O 99 OTHER <br /> VI.TANK CLOSURE INFORMATION <br /> 1.ESTIMATED DATE LAST USED(MO/DAY/YR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES O NO <br /> SUBSTANCE REMAINING GALLONS INERTMATERIAL7 <br /> THIS FORM HAS BEEN COMPLETED UNDER PENAL TY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT <br /> APPLICANTS NAME DATE <br /> IPRIXTE0651GNATUREI <br /> LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW <br /> COUNTY# JURISDICTION# FACILITY# TANK <br /> STATE LD.# Llo Yvr Lb <br /> PERMITNUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE G </_� 5, L/JZ <br /> FORM B (9-90) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. <br /> FORMSRA <br /> lftw <br /> J v �� <br />