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. ( aov-cPs STATE OF CALIFORMA STATE WATER RESOURCES CONTROL BOARDl�� UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM B ..3 n COMPLETE A SEPARATE FORM FOR EAt<TANK SYSTEM. MARK'ONLY ❑ 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION a 7 PERMAN Y LOS D O' ITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK ED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: Icq ae-o FAL 1.10- oS LI S cy�Z f11/i7f�' 4-J I. TANK DESCRIPTION COMPLETE ALL ITEMS— SPECIFY IF UNKNOWN A. OWNER'S TANK 1.D.aI _us-lL—12. I 8. MANUFACTURED BY: U�1�u�1rL C. DATE INSTALLED(MO/DAY/YEAR) -T--� 0. TANK CAPACITY IN GALLONS: `0 d0 0 i II.TANK CONTENTS IFA-1 IS MARKED.COMPLETE ITEM C. �'^/r �� 1.�t MOTOR VEHICLE FUEL ❑ a OIL 8. C. !, aUNLEAOED f� 3 DIESEL _ g AVIATION GAS A. u �j d GASAHOL 2 PETROLEUM ❑ 30 EMPTY i &t 1 PRODUCT Q lb PREMIUM S JET FUEL L 7 METHANOL ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN 2 WASTE ❑ 2 LEADED 99 OTHER (DESCRIBE IN ITEM 0. BELOW), 0. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S.III: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.S.AND C.AND ALL THAT APPLIES IN BOX O AND E A. TYPE OF ❑ 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM Cbr2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER B. TANK ❑ 1 BARE STEEL 2 STAINLESS STEEL Cy�3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL Q 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE 7 ALUMINUM ❑ 8 100%METHANOL COMPATIBLE WFRP (Primary Tank) Ci 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 IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? YES, NO_ 0.CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP �1 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) IV.PIPING INFORMATION CIRCLE A IFABOVEGROUNOOR U IF UNDERGROUND.BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION A Q2 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 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 VW COATING A U 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 0. LEAK DETECTION j� 1 AUTOMATIC LINE LEAK DETECTOR C� UNE TIGHTNESS TESTING IMNCT ItKi 99 OTHER V.TANK LEAK DETECTION ❑E<1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ® 3 VADOZE MONITORING ® 4 AUTOMATIC TANK GAUGING❑ 5 GROUND WATER MONITORING ❑t,-9 TANK TESTING 1: 7 INTERSTITIALMONTTORING ❑ 91 NONE ® 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION 1.ESTIMATED DATE LAST USED(MO/DAY/YR) I 2.ESTIMATED QUANTITY OF I 3.WAS TANK FILLED WITH -� YES E] NO SUBSTANCE REMAINING GALLONS INERT MATERIAL? THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANTS NAME (PRINTED&SIGNATURE) GATE 2 24.4 Z. LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FO NUMBERS BELOW COUNTY# JURISDICTION# FACILITY# _ TANK# STATE LD.#� � �>�' &,,147 , PERMIT NUMBER 1 PERMIT APPROVED BY/DATE i PERMIT EXPIRATION DATE j � I FORM B (7-91) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. FOR00548«:5