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• • 'eh VP a co STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMI APPLICATION.FORM B C�L,fOPPf COMPLETE A SEPARATE FORM FOR ACH TANK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED ON SITE ONE ITEM ❑ 2 INTERIM PERMIT 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE B TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: // S, San I. TANK DESCRIPTION COMPLETE ALL ITEMS-- SPECIFY IF UNKNOWN B. MANUFACTURED BY: uCL A. OWNER'S TANK I.D.It Q C. DATE INSTALLED(MO/DAYNFAR) GALLONS: '75--ofJ ILTANKCONTENTS IFA-11SMARKED,COMP EMC. la REGULAR ❑ 3 DIESEL 6 AVIATION GAS ❑ 1 MOTOR VEHICLE FUEL 4 OIL B. / C. UNLEADED ❑ 4 GASAHOL ❑ A. 2 PETROLEUM 80 1 PRODUCT lb PREMIUM ❑ 7 METHANOL ❑ 3 CHEMICAL PRODUCT ❑ EMPTY ❑ ❑ UNLEADED ❑ UEL 95 UNKNOWN 2 WASTE ❑ 2 LEADED g9 OTHER (DESCRIBE IN ITEM D. BELOW) D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S.4: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.B.ANDC,AND LTH APP IN BOX- ` ❑ 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH TERIOR R ❑ 95 OWN / A- ✓ e / A. TYPEEM ❑ 4 SECONDARY CON IN NT ( EDT 99 OTHER �N.lI�' Off/ l SYSTEM ❑ 2 SING E WALL ❑ ARE STEEL ❑ 2 STAINLESS ST L 3 E GLASS E] 4 STEEL CLAD W/FIBERGLASS REINFORCED PLA B. TANK 6 POLYVINYL LORIDE INUM ❑ 9 100% METHANOL CAMPATISLE W/FRP MATERIAL 5 CONCRETE (Primary Tank) ❑ 9 BRONZE 10 GALVAN KNOWN ❑ 99 OTHER F-1 1 RUBBER LINED ❑ 2 ALKYD NING 3 FOXY LINING F 4 PHENOLIC LINING C.INTERIOR ❑ 5 GLASS LINING ❑ 6 UNLI D 5 UNKNOW ❑ 99 OTHER LINING IS LINING MATERIAL COMPATIBLE WITH 1 METHANOL? VE _ NO VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC D.CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 ATING ❑ PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 9 NONE 95 UNKNOWN 99 OTHER IV.PIPING INFORMATION CIRCLE A IFABOVE ROUNDOR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 9 B. CONSTRUCTION A U 1 SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 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 M A U 6 CONCRETE A U 7 STEEL W/UNK A U 99100% METHANOL COMPATIBLE W/FRP CORROSION A U 5 ALUMINU PROTECTION A U 9 GALVANIZED EEL p U 10 CATHODIC PROTECTION A U 14 D. LEAK DETECTION [:] i AUTOMAT IC ELEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING 9 MON ORING ❑99 OTHER V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 INVE TORY RECONCILIATION ❑ 3 POR MONITORING❑ 4 AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING ❑ 6 TANK TESTING ❑ 7 IN RSTITIAL MONITORING 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORM A ON .�•� 3.WAS TANK FILLED WITH 1.ESTIMAT DATE LAST USED NR) 2.ESTIMATED QUANTITY OF f_S� GALLONS INERT MATERIAL? VES [:] NO Q SUBSTANCE REMAINING 10 THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLED n E IS TRUE AND CORRECT APPLICANTS NAME (PRINTED 8 SIGNATURE) LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# TANK# STATE LD.# 3� PERMIT NUMBER PER MIT APPROVED BY/DATEPERMITS PIRATIO D EIC ]% FORM 8 (990) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORM A,UNLESS A CURRENT FORMA HAS B EN FILED. FOR0614B-R6