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�(a bed CVaa,a6 0 . '. iltil SfATEOFCAUFO:A U p �C STATE WATER RESOURCES CONTROL BOARD P S� UNDERGROUND STORAGE TANK PERMIT APPLICATION-FORM B COMPLETE A SEPARATE FORMFOREACH TANK SYSTEM zz MARK ONLY 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 1 JQ 6 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED ON SITE ONE REM 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT O TEMPORARY TANK CLOSURE O 6 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: CkW vS/> # • I4" 3 6 I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A. OWNER'S TANK I.D.# B. MANUFACTURED C. DATE INSTALLED(MO/DAVHEAR) 5 D. TANK CAPACI IN GALLONS: I ©QO ILTANKCONTENTS IFA-11S MARKED.COMPLETE ITEM C. A. ❑ 1 MOTOR VEHICLE FUEL 4 OIL B. ❑ Is REGULAR 8 3 DIESEL ❑ 6 AVIATION GAS 2 PETROLEUM ❑ SO EMPTY ❑ 7 PRODUCT ❑ 1b PREMIUM 4GASAHOL ❑ 7 METHANOL UNLEADED 5 JET FUEL ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN USED/ 2 WAS ❑ 2 LEADED 99 pTNER (DESCRIBE IN ITEM D. BELOW) D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED USES 0 1 L_ C.A.S.a: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A,B.AND ,AND ALL THAT APPLIES IN BOX D AND A. TYPE OF X 1 DOUBLE WALL ❑ 3 SINGLE WA ITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM ❑ 2 SINGLE WALL ❑ 4 SECOND CONTAINMENT (VAULTED TANK) ❑ 99 OTHER ❑ 1 BARE STEEL ❑ 2 STAIN SS STEEL 3 FIBERGLASS ❑ 4 STEELCLAD WIFISERGLASS REINFORCEOPLASTIC B. TANK MATERIAL ❑ 5 CONCRETE ❑ e PO INYL CHLORIDE ❑ 7 ALUMINUM � S 100% METHANOL COMPATIBLE W/FRP (PrimaryTank) ❑ 9 BRONZE Ed10 LVANIZED STEEL E] 95 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED 2 ALKYD LWWG ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING C.INTERIOR ❑ 5 GLASS LINING 6 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER LINING IS LINING MATERIAL COMPATIB WITH 100%METHANOL? YES4 NO_ D.CORROSION ❑ 1 POLYETHYLENE W P ❑ 2 COATING ❑ 3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PRO CTION ❑ 91 NONE E]95 UNKNOWN 99 OTHER E.SPILL AND OVERFILL SPILL CO AINMENT INSTALLED(YEAR) 1990 OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) Iii 95 IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND.BOTH IF APPLICABLE A. SYSTEM TYPE A U SUCTION A U 2 PRESSURE AG 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A 1 SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAVION U 1 BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A U 4 FIBERGLASS PIPE CORROU 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL W/COATING A© S 100% METHANOL COMPATIBLE W/FRP PROTECU 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER D. LEAK DE � 1 AUTOMATIC LINE LEAKDETECTOR ❑ 2 LINE TIGHTNESS TESTING ❑ G MONTORING ❑99 OTHER V.TANK AK DETECTION ❑ VISUAL CHECK 2 INVENTORY RECONCILIATION ❑ 3 VADOZE MONITORING '711 4 AUTOMATIC TANK GAUGING ❑ 5 GROUNDWATER MONITORING 6 TANK TESTING 7 INTERSTITIAL MONITORING ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION 1.ESTIMATED GATE LASTi'S (�(MOIDAV/YR) 2.ESTIMATED QUANTITY OF ^ 3.WAS TANK FILLED WITH YES ❑ NO ❑ 1`r H SUBSTANCE REMAINING IT-" GALLONS INERT MATERIAL? THIS FORM HAS B EN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANTS NAME y�L� �( ��/�/ //� DATE / Q/ (PLANTED A SIGNATURE) STAIN C 1\ ( rr� ( '' -• P, • 5 LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW Rp COUNTY# JURISDICTION# FACILITY# - TANK# S�- STATE I.D.# m PERMIT NUMBER PER MIT APPROVED BY/DATE PERMIT EXPIRATION DATE THIS FORM MUST BE AC�ANIED BY A PERMIT APPUCATION•FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. FILE THIS FORM W E LOCAL AGENCY IMPLEMENTING THE UNDERGROUN AGE TANK REGULATIONS FORMS 112911 — I q — q/A6 FOR0m16%