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y0� STATE OF CALIFORNIA t STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. c""° MARK ONLY 15< 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION O 7 PERMANENTLY CLOSED ON SIT ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE O 8 TANK REMOVED C) I DBA OR FACILITY NAME WHERE TANK IS INSTALLED: WoJt oo S Vied( ❑ 4 STEEL CLAD W/ FIBERGLASS REINFORCED PLASTIC 4315lJI�I,T-�i+� UIOp I�oaa J-10ax jw , 6* I. TANK DESCRIPTION COMPLETE ALL ITEMS - SPECIFY IF UNKNOWN A. OWNER'S TANK I. D. a -75Z4 -25 - PRE-/ B. MANUFACTURED BY: -e-f �e C C. DATE INSTALLED (MO/DAY/YEAR) I - 015 D. TANK CAPACITY IN GALLONS: 151 00 O II. TANK CONTENTS IFA-11SMARKED.COMPLETEITFMC. A. 1 MOTOR VEHICLE FUEL 4 OIL U ❑ B. C. ❑ NIGAS � l& REG DELAR 3 DIESEL 8 AVIATK H ❑ 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 (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 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 F72 STAINLESS STEEL ® 3 FIBERGLASS ❑ 4 STEEL CLAD W/ FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM 8 100% METHANOL COMPATIBLE W/FRP (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER A U ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING C. INTERIOR ❑ 5 GLASS LINING 6 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER LINING D. LEAK DETECTION � 1 AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING 9 TIT LA MONK ❑ 99 OTHER 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) ( S IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND, BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION q 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL AQ 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 Q 4 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL W/ COATING A ()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 9 TIT LA MONK ❑ 99 OTHER V. TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VADOZE MONITORING 0 4 AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING ❑ 6 TANK TESTING �g 7 INTERSTITIAL MONITORING ❑ 91 NONE ❑ 95 UNKNOWN a 99 OTHER VI. TANK CLOSURE INFORMATION 1. ESTIMATED DATE LAST USEDMO/ AY/YR) 2. ESTIMATED QUANTITY OF 3, WAS TANK FILLED WITH YES ❑ NO ❑ 1 . SUBSTANCE REMAINING .GALLONS INERT MATERIAL? THIS FORM HAS BEEN COMPLETED UNDER PENALTY RJU , SND TOITHEJES A Y NO LEDGE, IS TRUE AND CORRECT APPLICANTS NAME DATE (PRINTED B SIGNATURE)4K ''�j .L A /?1 yn ��. t Z� / �-j LOCAL AGENCY USE ONLY THE STATE LD. N MBER COMPOSED'O HE FOU OUM6S BELOW COUNTY # JURISDICTI FACILITY # TANK A STATE I.D.# 2 3 ( 5-v 3 PERMIT NUMBER F PERMIT APPROVED BY/DATE I 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 THr LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STC"" 3E TANK REGULATIONS FORM B (12-91) FOR0034111-A6