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II STATE OF CALIFORNIA I(qa STATE WATER RESOURCES CONTROL BOARD / Tow, UNDERGROUND STORAGE TANK PERMIT APPLICATION • FORM B � 0 1`J G COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM °�.. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ONSITE 'L��D�' ONE ITEM ❑ 2 INTERIM PERMIT �4 AMENDED PERMIT ❑ 8 TEMPORARY TANK CLOSURE O 8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: IS-3-3 L/Ajw o S- OC�c oy I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN 1 2 A. OWNER'S TANK I.D.# 13 TA n I 1 OI MANUFACTURED BY: C. DATE INSTALLED(MO/DAYNEAR) ll - 9D D. TANK CAPACITY IN GALLONS: d OQQ 11.TANK CONTENTS tFA-1 ISMARKED.00MPLETEITEMC. A. Q 1 MOTOR VEHICLE FUEL 4 OIL B. C. ❑ 1aUNLEA ED REGULAR e 3 DIESEL ❑ g gyIATION GAS F-12 PETROLEUM ED so EMPTY Cd1 PRODUCT ❑ 1b PREMIUMT�I 4 GASAHOL ❑ 7 METHANOL ❑ ❑ ❑ ❑ UNLEADED � 9JE L 3 CHEMICAL PRODUCT 95 UNKNOWN 2 WASTE 2 LEADED u9 OTHER (DESCRIBE IN ITEM D. BELOW) D. IF(A.1)IS NOT MARKED. ENTER NAME OF SUBSTANCE STORED 0;/ C.A S.8: 111. TANK CONSTRU TION MARK ONE ITEM ONLY IN BOXES A.B.ANDC.AND ALLTHATAPPLIES 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 F-] 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ g POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP (Primary Tank) O 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING Q 4 PHENOLIC LINING C.INTERIOR LINING F-15 GLASS LINING ❑ g UNLINED F-1 95 UNKNOWN ❑ 99 OTHER IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? VES_ NO— D.CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE ❑95 UNKNOWN ❑ 99 OTHER IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IFUNERGROUND,BOTH IFAPPUCABLE A. SYSTEM TYPE A VI SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A U / SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER 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 5 ALUMINUM A U 8 CONCRETE A U 7 STEEL W/COATING A U 8 100% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION ❑ 1 AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING ❑ 3 WNROITNGL ❑ B9 OTHER V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ INVENTORY RECONCILIATION ❑ 3 VAPOR MONITORING E:] 4 AUTOMATIC TANK GAUGING ❑ 5 GROUNDWATER MON ❑ 8 TANK TESTING I7 INTERSTITIAL MONITORING ❑ 91 NONE ❑ 95 UNKNOWN F-199 OTHER ITORING VI.TANK CLOSURE INFORMATION 1.ESTIMATED DATE LAST USED(MO/DAY/YR) 2.ESTIMATED GUANTITY OF 3.WAS TANK FILLED WITH YES NO SUBSTANCE REMAINING GALLONS INERT MATERIAL? THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANTS NAME DATE IPRNTEO A SIGNATURE) LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY# �TANK-#� STATE I.D.# ® j g I I 11 11/ k] STouVS PERMIT NUMBER PERMIT APPROVED BY/DATE C FORM B (9 901 THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. - //�j/?- — FORaoaa3Zt