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STATE OF CALIFORNIA -e"�wV, i STATE WATER RESOURCES CONTROL BOARD i / UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B .tl o � : o n COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. c"`�"°""�" MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT EVS CHANGE OF INFORMATION 7 PERMANENTLY CL ITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 8 TEMPORARY TANK CLOSURE ❑ B TANK REMOVED OBA OR FACILITY NAME WHERE TANK IS INSTALLED: L%� �,�j} / -✓L �J.2. 1 G y S��GI I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN / A. OWNERS TANK I.D./ B. MANUFACTURED BY: C. DATE INSTALLED(MO/DAYrYEAR) D. TANK CAPACITY IN GALLONS: V V ls� II.TANK NTENTS IF A4 IS MARKED.COMPLETE ITEM C. L/ 1 MOTOR VEHICLE FUEL ❑ d OIL B. C. ❑ 1iUNLEA ED 3 DIESEL ❑ A. 6 AVIATIONGAS ❑ 2 PETROLEUM ❑ 80 EMPTY 1 PRODUCT ❑ Ib PREMIUM d GASAHOL ❑ 7 METHANOL ❑i UNLEADED 3 CHEMICALPROOUCT ❑ 2 LEADED 95 UNKNOWN ❑ 2 WASTE ❑ ❑ 99 OTHL OTHER (DESCRIBE IN ITEM 0. 8ELOM ❑ D. 'F(A.1)IS NOT MARKED. ENTER NAME OF SUBSTANCE STORED C.A.S.4: III. TANK CONSITTRRUCTION MARK ONE ITEM ONLY IN BOXES A B.AND C.AND ALL THAT APPLIES IN BOX A. TYPE OF ❑ 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM ® 2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER B. TANK I BARE STEEL ❑ 2 STAINLESS STEEL C:] 3 FIBERGLASS ❑ 4 STEEL CLAD WI FIBERGLASS REINFORCED PLASTIC MATERIAL 5 CONCRETE ❑ 8 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP (PrimaryTank) ❑ 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 95 UNKNOWN LINING El 99 OTHER ''��sS'' IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO_ 0.CORROSION ❑ 1 :POLYETHYLENE WRAP ❑ 2 COATING 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE 1%95 UNKNOWN ❑ 99 OTHER IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND.BOTH IF APPLICABLE A. SYSTEM TYPE A U I SUCTION A U 2 PRESSURE A U 3 GRAVITY A W OTHER S. CONSTRUCTION A U I SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH 95 UNKNOWN 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 CORROSION A U 5 ALUMINUM A U 8 CONCRETE A U 7 STE P COATING A U 8 100% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION U UNKNOWN A U 99 OTHER D. LEAK DETECTION ❑ t AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING ❑ MONITORING ❑ 99 OTHER V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VAPOR MONITORING❑ 4 AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING ❑ 6 TANK TESTING ❑ 7 INTERSTITIAL MONITORING ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION 1.ESTIMATED DATE UST USED(MO/DAYNR) 2.ESTIMATED QUANTITY OF1 WAS TANK FILLED WITH SUBSTANCE REMAINING GALLONS INERT MATERIAL 7 YES ❑ NO®" THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE IS TRUE AND CORRECT APPLICANTS NAME IvwrvTeoaslcrunPO DATE LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OFTHE FOUR NUMBERS BELOW L /^J COUNTY# JURISDICTION A FACILITY 6 TANK 6 STATE I.D.# -'' � vr-I �, PERMITNUMBER PERMITAPPROVED BY,DATE PERMIT EXPIRATION DATE FORMS (490) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION"FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. FOR09M&R4