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• STATE OF CALIFORNIA • a STATE WATER RESOURCES CONTROL BOARDUNDERGROUND STORAGE TANK PERMIT APPLICATION . FORM BCOMPLETE A SEPARATE FORM FOR E TANK SYSTEM, MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTL ED ON ONE ITEM ❑ 2 INTERIM PERMIT ❑ a AMENDED PERMIT ❑ 8 TEMPORARY TANK CLOSURE ❑ 8 TANK REM ED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: d h 7X I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A OWNER'S TANK 1.0.a B. MANUFACTURED By: �IL C. DATE INSTALLED(MDrDAYKEAR) I& 0. TANK CAPACITY IN GALLONS: S� II.TANK CONTENTS IF A•1 IS MARKED,COMPLETE ITEM C. A. 7 1 MOTOR VEHICLE FUEL ❑ 4 OIL 8. C. 1aEAA 3 DIESEL ❑ ❑ e AVIATION GAS 2 PETROLEUM 80 EMPTY 1 PUNLD RODUCT IE PREMIUM B d GASAHOL ❑ 7 METHANOL ❑ 3 CHEMICALPRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED ❑ 5 JETFUEL ❑ D. IF(A.11 IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED D99 OTHER (DESCRIBE IN ITEM D. BELOM C.A-3.a: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A B.AND C.AND ALL THATAPPLIES IN BOX A. TYPE OF ❑ I DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM ❑ 2 SINGLE WALL ❑ A SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER B. TANK ❑ I BARE STEEL ❑ 2 STAINLESS STEEL 3 FIBERGLASS ❑ a STEEL CLAD Wt FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ S CONCRETE ❑ 8 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP (Pr(maryTank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN 9g OTHER C.INTERIOR I RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ A PHENOLIC LINING LINING ❑ 5 MUSS LINING ❑ 8 UNLINED ❑ 93 UNKNOWN ❑ 99 OTHER IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO— D.CORROSION ❑ I POLYETHYLENE WRAP 2 COATING ❑ 3 VINYL WRAP ❑ d FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE ❑95 UNKNOWN ❑ W OTHER IV.PIPING INFORMATION CIRCLE A IFABOVEGROUNOOR U IFUNOERGROUND.BOTH IF APPLICABLE A. SYSTEM TYPE A U I SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 29 OTHER B. CONSTRUCTION A U I 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 RARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A U a FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U B 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 ❑ 1 AUTOMATIC LINE LEAK DETECTOR 2 LINE TIGHTNESS TESTING3IN S ML ❑ MONROflING ❑ 99OTHER V.TANK LEAK DETECTION +( ❑ 1 VISUAL CHECK ❑ 2 INVENTOflY RECONCILIATION ❑ 3 VAPOR MONITORING❑ l TCMATIC TANK GAUGING❑ 5 GROUND WATER MONITORING �`1 ❑ 8 TANK TESTING ❑ 7 INTERSTITAL MONITORING ❑ 91 NONE 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION 1.ESTIMATED DATE UST USED(M nA) 2.ESTIMATED OUANTITY OF 3.WAS TANK FILLED WITH SUBSTANCEREMAINING �") GAILLONS INERTMATERIAL? YES [:] NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT APPLICANTS NAME (PPoHTE9a 9i0NATUPEI DATE LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW /! COUNTY N JURISDICTION N FACILI[TY N TANK N STATE LD.# FU I Tl PERMIT NUMlen CoM/r A7 PERM IT APPROVED BY/OA I E - PERJMIT EXPIRATION DATE FORMS (9.9o) THIS FO'RL/M,MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. F011t041"Rt to w 0J