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STATE OF CALIFORNIA �•••'••,c STATE'WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B I< COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. NARK ONLY ❑ I NEW PERMIT ❑ 0 RENEWAL PERMIT 5 CHANCE OF INFORMATION ❑ 7 PERMANENTLY CLO ' SITE CNE TEM ❑ 2 INTERIM PERMIT ❑ a AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 6 TANK REMOVED 08A OR FACILITY NAME WHERE TANK IS INSTALLED: LLL7 b IV I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A. OWNER'S TANK I.0.s S. MANUFACTURED BY: C. DATE INSTALLED(MCfOAYlNEAR) I D 0. TANK CAPACITY IN GALLONS: Q � It.TANK CONTENTS IFA•IISMAAKEO.COMPLETEITEMC. AllII��''''I A. [71 MOTOR VEHICLE FUEL ❑ a OIL 8. C. ❑ IAUNLEA EDIESEL e AVIATION GAS RED PREMIUM U a DGAS,VIOL ❑ ❑' 2 PETROLEUM ❑ 80 EMPTY ❑ 1 PRODUCT 1eUNLEAOED 5 :ET FUEL 1:1 7 METHANOL ❑ 7 CHEMICALPRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED 99 OTHER (DESCRIBE IN ITEN D. SELCq 0. IF A.I)IS NOT MARKED. ENTER NAME OF SUBSTANCE STORED C.0.S.a: III. TANK CONSTRUCTION MARKONE ITEM ONLYINSOXES A.B.ANOC.ANOALLTHATAPPLIES INBOX0 A. TYPE OF ❑ 1 DOUBLE WALL ❑ 7 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM ❑ 2 SINGLE WALL ❑ A SECONDARY CONTAINMENT [VAULTED TANK) ❑ 99 OTHER S. TANK ❑ I BRAE STEEL ❑ 2 STAINLESS STEEL ❑ 2 FIBERGLASS ❑ a STEEL CLAD W1 FIBERGLASS REINFORCZO PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 6 100% METHANOL COMPATIBLE W/FRP (Primuy Tank) 9 BRONZE ❑ 10 GALVANQSO STEEL ❑ 96 UNKNOWN ❑ S9 OTHER ❑ 1 RUBBER LINED 2 ALKYD LINING ❑ 0 EPDXY LINING C] A PHENOLIC LINING C.IHNGR 775 GLASS LINING ❑ 6 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER LINING NN IS LINING MATERIAL COMPATIBLE WITH 100'A METHANOL? YES_ NO_ 0.CGRRO$ION ❑ I POLYETHYLENE WARP ❑ 2 COATBK6 cl 0 VINYL WRAP ❑ A FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHCOIC PROTECTION ❑ 91 NONE = 95 UNKNOWN ❑ N OTHER IV.PIPING INFORMATION CIRCLE A IFABOVEGRCUNOOR U IFUNCERGROUNO.BOTHIFAPPUCABLE A. SYSTEM TYPE A U I SUCTION A U 2 PRESSURE A U 0 GRAVITY A U 99 OTHER B. CONSTRUCTION A U I SINGLE WALL A U 2 DOUBLE WALL A U S LINED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MA i ORIAL AND A U I BARE STEEL A U 2 STAINLESS STEEL A U 2 POLYVINYL CHLORIDE(PVC)A O a FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL WICOATM A U 6 IOW. METHANOL COMPATIBLE'NIFRP PROTECTION A U 2 GALVANQEO STEEL A U 10 CATHCDICPROTECTICN A U 95 UNKNOWN A U 99 OTHER 0. LEAK DETECTION ❑ I AUTOMATIC LINE LEAK DETECTOR 2 LINE TIGHTNESS TESTING ❑ yCNR0RW0 C:]TIERSTITt99 OTHER V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 INVENTORY RECONCAIATCN ❑ 2 VAPOR MONITORING❑ a AUTOMATIC TANKGAUGING ❑ 5 GROUND''WA ERMCNITCRING ❑ 6 TANK TESTING ❑ 7 INTERSTMALMONITORING ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION I.ESTIMATED DATE UST USED(MOIDAYNR) I 2.ESTIMATED QUANTITY OF 2.WAS TANK FILLED WITH YES ❑ NO❑ SUBSTANCE REMAINING GALLONS I INERT.MATERIAL? THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF,NY KNOWLEDGE, IS TRUE ANO CORRECT APPLICANTS NAME GATE IPWMEDA SK TVAO LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW W LLZ q Z, COUNTY 9 JURISOICTICN S FACILITY 0 TANK x STATE 1.044 EE 1016111 PERMIT NUMBER PERMIT APPROVED SYIOAT'E PERMIT EXPIRATION DATE FORM B (9.991 THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. wao0v6.u1( /�/