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STATE OF CALIFORNIA • •� STATE WATER RESOURCES CONTROL BOARD +` UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM B COMPLETE A SEPARATE FORM FOR CH TANK SYSTE MARK ONLY ❑ 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATI N PERMA TLY CLOSED ON SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORAR�Y.,T�A.N,K1 CLOSURE �B TANK REMOVED DBAOR FACILITY NAME WHERE TANK IS INSTALLED:1311.6rllp .- I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A. OWNER'S TANK I.O.# A'C/�lt._` � S. MANUFACTURED BY: C. DATE INSTALLED(MO/DAY YEAR))1I,577Qj D. TANK CAPACITY IN GALLONS: I01 l� 07 ILTANKCONTENTS IFA-11S MARKED,COM PLETE ITEM C. a REGULAR 3 DIESEL ❑ 6 AVIATION GAS A 1 MOTOR VEHICLE FUEL ❑ 4 OIL 8. C UNLEADED 4 GASAHOL Q 2 PETROLEUM ❑ 80 EMPTY PRODUCT ❑ IbUM UN ELIDED ❑ 5 JET FUEL ❑ 7 METHANOL Q 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED ❑ 99 OTHER (DESCRIBE IN ITEM D. BELOW) D. IF(A.1)IS NOT MARKED. ENTER NAME OF SUBSTANCE STORED C.A.S. III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A,9.AND C.AND ALLTHAT APPLIES IN BOXDANDE ❑ 1 DOUBLE WALL F7 3 SINGLE WALL WITH EXTERIOR LINER 95 UNKNOWN A. TYPE OF SYSTEM ❑ 2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B. TANK 5 CONCRETE ❑ 8 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP MATERIAL ❑ (Primary Tank) ❑ 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 UNLINED E�95 UNKNOWN ❑ 99 OTHER LINING IS LINING MATERIAL COMPATIBLE WITH 100% ME rHANOL? YES_ NO_ ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC O.CORROSION PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE Y95UNKNOWN ❑ 99 OTHER E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION A 02 PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A 095 UNKNOWN A U 99 OTHER y C. MATERIAL AND A U 1 BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A U 4 FIBERGLASS PIPE CORROSION A U S ALUMINUM A U B CONCRETE A U 7 STEEL WI COATING A U B 100% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A095 UNKNOWN A U 99 OTHER D. LEAK DETECTION ❑ 1 AUTOMATIC LINE LEAK DETECTOR 2 LINE TIGHTNESS TESTING ❑ 3 ApNRORING ❑ 99 OTHER V.TANK LEAK DETECTION E�rl� VISUAL CHECK �2 INVENTORY RECONCILIATION ❑ 3 VAD07E MONITORING ❑ 4 AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING ER 6 TANK TESTING ❑ 7 INTERSTITIAL MONITORING ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION 1.ESTIMATED ATE LAST USED(MO/OAY/YR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES NO d SUBSTANCE REMAINING O GALLONS INERT MATERIAL? THIS FORM HAASl/BEEN //COMPLETED UNDER PENALTY OF PERJURY,AN THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANT'S NAME�' ,) jQ�+C�. �%CJ{'L. DATE � IPRINTEG A 91GNATURE7 LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF E FOU UMBERS B OW COUNTY# JURISDICTION# FACILITY# TANK# STATE I.D F�[q F= Q O I O O O D PERMITN PERMIT APPROVED BY/OATS tel . PERMIT EXPIRATION DATE FORMS (7-91) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. FOR067/BR5