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v 0-7 STATE OF CALIFORNIA' STATE WATER RESOURCES CONTROL BOARD Abo UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM B COMPLETE A SEPARATE FORM FOR TA EACH�� NK SYSTEM. J MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 2!--5CHANGE OF INFORMATION F-1 7 PERMANENTLY CLOSEl 57ITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVEq DBA OR FACILITY NAME WHERE TANK IS INSTALLED: C;7 Coo,,j-y V-e- 1. TANK DESCRIPTION COMPLETE ALL ITEMS-- SPECIFY IF UNKNOWN A. OWNER'S TANK I.D.X B. MANUFACTURED BY: C. DATE INSTALLED(MO/DAY/YEAR) D. TANK CAPACITY IN GALLONS: ILTANKCONTENTS IFA-1 IS MARKED,COMPLETE ITEM C. CE] I a REGULAR 3 DIESEL, 6 AVIATION GAS A. 0 1 MOTOR VEHICLE FUEL ❑ 4 OIL C. UNLEADED H ❑ 2 PETROLEUM ❑ 80 EMPTY ❑ I PRODUCT 4 GASAH lbPREMIUM 7 METHANOL ❑ UNLEADED JE:T/dEL 3 CHEMICALPRODUCT 0 95 UNKNOWN Ej 2 WASTE 2 LEADED F-] :eTHER (DESCRIBE IN ITEM D. BELOW) D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED 1-100C.A.S.Ir 111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A,B.AND C,AND ALL THAT APPLIES IN BOX D AND A. TYPE OF F-] 1 DOUBLE WALL F-] 3 SINGLE WALL WITH EXTERIOR LINER 95 UNKNOWN SYSTEM D 2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTEDTAN ❑ 99 OTHER F--] I RARE STEEL E] 2 STAINLESS STEEL F-� ER S E] 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B I B. 'TANK F-� INU F-1 8 100% METHANOL COMPATIBLEW/FRP MATERIAL , 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE M E:] 9 BRONZE (PdmaryTank) 10 GALVANIZED STEEL ❑ UNKNOWN ❑ 99 OTHER F-] 1 RUBBER LINED E] 2 ALKYD LINING 3 EPDXY LINING ❑ 4 PHENOLIC LINING C.INTERIOR F--j 5 GLASS LINING Ej 6 UNLINED ❑ 96 UNKNOWN ❑ 99 OTHER LINING 0 YES IS LINING MATERIAL COMPATIBLE WITH 100% METHANI/— NO— D.CORROSION F-] 1 POLYETHYLENE WRAP 0 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION E::] 5 CATHODIC PROTECTION El 91 NO ❑95 UNKNOWN ❑ 99 OTHER E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED AR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) IV.PIPING INFORMATION CIRCLE A IFABOV /ROUND 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 U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND A U 1 BARE STE A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A U 4 FIBERGLASS PIPE J/ CORROSION A U 5 ALUM! A U 6 CONCRETE A U 7 STEEL WICOATING A U 8 100% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GAL NIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION ❑ 1 A/OMATIC LINE LEAK DETECTOR 0 2 LINE TIGHTNESS TESTING ❑ 3 IWERSTIT14L MONITORING 0 99 OTHER V.TANK LEAK DETECTI�X( ❑ 1 VISUAL CHECK 2 INVENTORY RECONCILIATION ED 3 VADOZE MONITORING 4 AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING D 6 TANK TESTI;;/'no 7 INTERSTITIAL MONITORING ❑ 91 NONE 0 95 UNKNOWN E::] 99 OTHER VI.TANK CLOREINFORMATION TIMATEDE LAST USED(MO/DAY/YR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH E] ESTIMATED XTI SUBSTANCE REMAINING GALLONS INERT MATERIAL? 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&SIGNATURE) LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW -Z 3 4 t COUNTY# JURISDICTION# FACILITY# r KTAINK 1 , STATE I.Ell [n] I I ---Fl PERMIT NUMBER I PERMIT APPROVED BY/DATE PERMIT EXFIFRAtbN Ysc THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND ST GE TANK REGULATIONS 0 � FORM B (12-91) .I L- 10- r -116