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,oma" STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B� 1 y 0 COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY �?S 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ON SITI ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT//�� ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED V t DBA OR FACILITY NAME WHERE TANK IS INSTALLED: Gl 100 S 6t � 456 Wo -W100 (PrimaryTank) sioCA-I CA I. TANK DESCRIPTION COMPLETE ALL ITEMS — SPECIFY IF UNKNOWN A. OWNER'S TANK I. D. 0 -75 Z4 -1 S ar7 _ _ B. MANUFACTURED BY: 7y as C. DATE INSTALLED (MO/DAY/YEAR) 1 —q5 D. TANK CAPACITY IN GALLONS: I '5' OO D II. TANK CONTENTS IFA -1 IS MARKED. COMPLETE ITEM C. A X 1 MOTOR VEHICLE FUEL ❑ 4 OIL B.C.. I& REGULAR3 DIESEL L]6 AVIATION GAS ❑ 2 PETROLEUM ❑ 80 EMPTY 1 PRODUCT ❑ 1b PREMIUM 4 GASAHOL ❑ 7 METHANOL UNLEADED ❑ 5 JETFUEL ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED ❑ 99 OTHER (DESCRIBE IN ITEM D. BELOW) D. IF (Al) IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C. A. S. s: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A. 8. AND C. AND ALL THAT APPLIES IN BOX D AND E A. TYPE OF .I^I 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM ❑ 2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER A &1 2 DOUBLE WALL A U ❑ i BARE STEEL ❑ 2 STAINLESS STEEL ® 3 FIBERGLASS ❑ 4 STEEL CLAD W/ FIBERGLASS REINFORCED PLASTIC B. TANK MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM 8 100% METHANOL COMPATIBLE W/FRP (PrimaryTank) ❑ 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 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 E. SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED (YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED (YEAR) I IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND, BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION A 6>2 PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL A &1 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND CORROSION PROTECTION A U A U A U 1 BARE STEEL 5 ALUMINUM 9 GALVANIZED STEEL A U 2 STAINLESS STEEL A U A U 6 CONCRETE A U A U 10 CATHODIC PROTECTION 3 POLYVINYL CHLORIDE (PVC) A 6) 4 FIBERGLASS PIPE 7 STEEL W/ COATING A® 8 100% METHANOL COMPATIBLE W/FRP A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION ;W1 AUTOMATIC LINE LEAK DETECTOR E 2 LINE TIGHTNESS TESTING LSI, 3 MOERSTITLAL ITORING ❑ 99 OTHER V. TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VAD07E MONITORING 4 AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITOR INC ❑ 6 TANK TESTING 7 INTERSTITIAL MONITORING ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER VI. TANK CLOSURE INFORMATION 1. ESTIMATED DAT AST USED (MO/DAY/YR) 2. ESTIMATED QUANTITY OF3. WAS TANK FILLED WITH YES [:]NO S ^ SUBSTANCE REMAINING GALLONS INERT MATERIAL 7 THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PfPIU#yAND TO tH, BES OF MI KN LEDGE, IS TRUE AND CORRECT APPLICANTS NAME tt (((l ��/// �n TE (PRINTED 8 SIGNATURE) / /� / / �l LOCAL AGENCY USE ONLY THE STATE I.D. NUMBE tS COM OSED OF THE FOvApMBERSkjLOW L� COUNTY x JURISDICTION aY FACILITY # TANK # STATE I.D.# ® � � � PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION • FORM A, UNLESS A CURRENT FORM A HAS BEEN FILED. FILE THIS FORM WITH T LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STS 3E TANK REGULATIONS FORM 9 (12-91) FOROM48•A{