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SauaceS STATE OF CALIFORNIA eP� . �o^ STATE WATER RESOURCES CONTROL BOARD a�. UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B WQ� 'a ol COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION n ;/PERMANENTLY CLOSE ITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE 8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: 2 3,r-13 /"'tv A0. LO16 T- !� I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A. OWNER'S TANK I.D.# G/ gDtV, B. MANUFACTURED BY: C. DATE INSTALLED(MO/DAY/YEAR) Iq"z)w D. TANK CAPACITY IN GALLONS: �Q ILTANKCONTENTS IFA-1 IS MARKED,COMPLETE ITEM C. A. 1 MF-]OTOR VEHICLE FUEL 4 OIL B. _ C. ❑ 1a REGULAR 3 DIESEL UNLEADED ❑ ❑ 6 AVIATION GAS ❑ 4 GASAHOL ❑ 2 PETROLEUM ❑ 80 EMPTY ❑��PRODUCT ❑ 1 UNLEADED I ❑ 5 JETFUEL ❑ 7 METHANOL ❑ 3 CHEMICAL PRODUCT ❑ 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 ALL THAT APPLIES IN BOX D AND E /''l: L,n(k A. TYPE OF ❑ 1 DOUBLE WALL ❑ 3 SINGLE WALL WITHEXTERIOR LINER E3--T5-UNKNOWN SYSTEM ❑ 2 SINGLE WALL ❑ 4 SECONDARY CONTAIVMENT (VAULTEDTANK) ❑ 99 OTHER_ B. TANK F-] 1 BARE STEEL ❑ 2 STAINLESS STEEL F73 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE: nALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP (Primary Tank) El BRONZE 1:110 GALVANIZED STEEL � 95 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING C.INTERIOR LINING ❑ 5 GLASS LINING 716 UNLINED 95 UNKNOWN El99 OTHER IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO,--' D.CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING n 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE 2<5 UNKNOWN ❑ 99 OTHER E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A �11`5 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 6 CONCRETE A U 7 STEEL W/COATING A U 8 10(r/ METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A7'11')5 UNKNOWN A U 99 OTHER D. LEAK DETECTION ❑ 1 AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING ❑ 3 INTERSTITIAL 99 OTHER MONITORING ❑ V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VADOZE MONITORINGTOMATIC TANK GAUGING ❑ 5 GROUNDWATER MONITORING F--] 6 TANK TESTING ❑ 7 INTERSTITIAL MONITORING ❑ 91 NONE �95NKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION F STIMATED DATE LAST USED(MO/DAY/YR) 2• SUMMATEDSUBSTANCQUANTITY OF GALLONS 3 WAS TAN AL FILLED WI?H YES [:] NO ❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANTS NAME DATE (PRINTED a SIGNATURE) LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# TANK# STATE I.D.# U o PERMIT NUMBER PERMIT APPROVED BY/DATE PERMITEXPIRATION DATE 5-7 /t FORM a (7-91) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. (� J FOR0034B-RS