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r STATE OF CALIFORNIA `- STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM B iF Jr i C, COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. °��,�°.+• MARK ONLY IM 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ ? PERMANENTLY CLOSED ON SITE ONE ITEM ❑ 2 INTERIM PERMIT 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ e TANK ROVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: A+ EM�� I. TANK DESCRIPTION COMPLETE ALL ITEMS-- SPECIFY IF UNKNOWN iA. OWNER'S TANK I.D.# V K NO VJ A.$ B. MANUFACTURED BY: E C. DATE INSTALLED(MO/DAY/YEAR) V K �••,0 t✓ 0. TANK CAPACITY IN GALLONS: : 0 000 ILTANKCONTENTS IFA-11SMARKED,C0MPLETE ITEMC. A P4 1 MOTOR VEHICLE FUEL EJ4 OIL B. , C. ❑ taUN LE D 3 DIESEL � 6 AVIATION GAS ❑ 2 PETROLEUM ❑ 80 EMPTY 1 PRODUCT ❑ tb PREMIUM 4 GASAHOL ❑ T METHANOL UNLEADED ❑ 5 JETFUEL ❑ 3 CHEMICALPRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED ❑ 99 OTHER (DESCRIBE IN ITEM D. BELOW) D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S.# III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.B,AND C,AND ALLTHAT APPLIES IN BOX D AND A. TYPE OF 1w 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM ❑ 2 SINGLE WALL ❑ ;4 SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER B. TANK ❑ 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ® 4 STEELCLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 9. POLYVINYL CHLORIDE ❑ ? ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP (Primary Tank) ❑ 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 ❑ 99 OTHER N O^/ C LINING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ 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 I 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 U 1 SUCTION p 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL A©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 e 4 FIBERGLASS PIPE CORROSION A U S ALUMINUM A U 6 CONCRETE A U 7 STEEL W/COATING A U 8 100x 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 Lo�2 LINE TIGHTNESS TESTING ❑ 3 INTERSTITIAL ONBORING 99 OTHER V.TANK LEAK DETECTION j ❑ 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VADOZE MONITORING 4 AUTOMATICTANK GAUGING ❑ 5 GROUNDWATER MONITORING ❑ 6 TANK TESTING ® ? INTERSTITIAL MONITORING ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION 1.ESTI M T D A LAST USED(MO/DAY/YR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES ❑ NO SUBSTANCE REMAINING GALLONS INERT MATERIAL? THIS F RM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF KNOWLEDGE, IS TRUE AND CORRECT APPLICANTS NAME I )AN t`. ,t.l'-C--' • IL, DATE (PRINTED a SIGNATURE) -� A"bO GcRU`C ` J �7 �d LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSEDOF THE 611 NUMBERS BELOW 7 COUNTY# JURISDICTION# FACILITY# TANK* STATE I.D.# m PERMIT NUMBER PERMIT APPROVED BY/DATE PENIMIT EXPIRATIONDATE F� �0RM B (7-91) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORM A,UNLESS A CURRENT FORMA HAS BEEN FILED. I 1 V11A -/1'V I ` FOROOl4B.R5 l