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�~ STATE OF CALIFORNIA < STATE WATER RESOURCES CONTROL BOARD a UNDERGROUND STORAGE TANK PERMIT APPLICATION-FORM B o/� COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 6 CHANGE OF INFORMATION O 7 RMANENTLV CLOSED ONSITE ONE REM ❑ 2 INTERIM PERMIT O ♦ AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE TANK REMOVED Z�II I DBA OR FACILITY NAME WHERE TANK IS INSTALLED: 4X19' I. TANK DESCRIPTION COMPLETE ALL ITEMS— SPECIFY IF UNKNOWN A. OWNER'S TANK I.D.# B. MANUFACTURED BY: tAk II L' T C. DATE INSTALLED(MO/DAYNEAR) D. TANK CAPACITY IN GALLONS: ILTANKCONTENTS IF A-1 IS MARKED.COMPLETE ITEM C. A O�MOTOR VEHICLE FUEL ❑ 4 OIL B. C. ❑ 1AUN EALDED REGUAR3 DIESEL ❑ 6 AVIATIONGAS A GASAHOL ❑ 2 PETROLEUM ❑ 60 EMPTY &KIPRODUCT ❑ 1eUNEMIUm O 5 JET FUEL ❑ 7 METHANOL ❑ 3 CHEMICALPRODUCT F-1 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED a 99 OTHER (DESCRIBE IN ITEM O. BELOW) D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S.v: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A,B.AND C,AND ALL THAT APPLIES IN BOX D AND A. TYPE OF F-1 11 DOUBLE WALL O 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM L_ Z SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ ♦ STEELCLAD W/FIBERGLASS REINFORCEOPLASTIC B. TANK 6 POLYVINYL CHLORIDE 7 ALUMINUM MATERIAL ❑ s CONCRETE ❑ ❑ E] B 100% METHANOL COMPATIBLE W/FRP (Primary TAOt) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ ♦ PHENOLIC LINING C.INTERIOR E::] 5 GLASS LINING FA- LINING kl—UNLINED ❑ 95 UNKNOWN ❑ W OTHER IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO_ D.CORROSION ❑ i POLYETHYLENE WRAP ❑ 2 ATING F-13 VINYL WRAP ❑ A FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION 91 NONE O95 UNKNOWN ❑ 99 OTHER E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) IV.PIPING INFORMATION CIRCLE A IFABOVEGROUNDOR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A pp,,�� 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER AU B. CONSTRUCTION A 1 SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 96 UNKNOWN A U 99 OTHER C. MATERIAL AND A O 1 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 6 CONCRETE A U 7 STEEL W/COATING A U B 100% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U w OTHER D. LEAK DETECTION ❑ 1 AUTOMATIC LINE LEAK DETECTOR [6o^F LINE TIGHTNESS TESTING ❑ MONTORING ❑99 OTHER V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VADOZE MONITORING ❑ A AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING Qq TANK TESTING ❑ 7 INTERSTITIAL MONITORING ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION 1.ESTIMATED DATE LAST S D(MO/DAYN 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES NO El� SUBSTANCE REMAINING —� GALLONS I INERT MATERIAL? THIS FORM HAS BEEN cbMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANTS NAME nr1 APPLIE.A6,.S.NA .EI U` `�� LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW / COUNTY# JURISDICTIONS FACILITY TANK# Lf STATE I.D.# m = I I I I I I I li h h I f1lo NO PERMIT NUMBER PERMIT APPROVED BYIDATE PERMIT EXPIRATION DATE THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPUCATION•FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. FILE THIS FORM WITH TP-'OCAL AGENCY IMPLEMENTING THE UNDERGROUND STO"';E TANK REGULATIONS POEM B 112-91) `e N100 FOpme-I'll