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• • STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B 4� 0 COMPL A SEPARATE FORM FOR EACH TANK SYSTEM MARK ONLY ❑ 1 NEW PERMIT 3 RENEWAL PERMIT "�S CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ONSITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 6 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: 4. r I. TANK DESCRIPTION COMPLETE ALL ITEMS - SPECIFY IF UNKNOWN�� A. OWNER'S TANK 1. 0. s B. MANUFACTURED BY: C. DATE INSTALLED (MOIDAYlYEAfl)' ",g D. TANK CAPACITY IN GALLONS: II. TANK PONTENTS IFA -1 IS MARKED, COMPLETE ITEM C. A. t MOTOR VEHICLE FUEL ❑ 4 OIL B./ C. REGULARaUNLEADED 3 DIESEL ❑ 6 AVIATION GAS ❑ 2 PETROLEUM ❑ 60 EMPTY 1 PRODUCT ❑ ib PREMIUM 4 GASAHOL ❑ UNLEADED 5 JET FUEL 7 METHANOL 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN (❑ 2 WASTE ❑ 2 LEADED 99 OTHER (DESCRIBE IN ITEM D. BELOV 0. IF (A.1) IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C. A.S.r: 111. TANK CONSTRUCMON MARK ONE ITEM ONLY IN BOXES A. S. ANO 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 R B. TANK ❑ i BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBEAGLASS 4 STEEL CLAD W/ FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ B 10074 METHANOL COMPATIBLE W/FRP (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED ❑ 2 ALKYO LINING E�95 EPDXY LINING 4 PHENOLIC LINING C. INTERIOR f—? 5 GLASS LINING 6 UNLINED/LINING LJ ❑ UNKNOWpY ❑ 99 OTHER IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES _ No D. CORROSION ❑ I POLYETHYLENE WRAP ❑ 2 XCrATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER E. SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED (YEAR) OVERFILL PREVENTION EOUIPMENT INSTALLED (YEAR) IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND. BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION 2 PRES A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL U 2 B W A U LINED TRENCH A U 98 UNKNOWN 99 OTHER C. MATERIAL AND A U 1 BARE STEEL A 4 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 6 100% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHCOIC PROTECTION A U 95 UNKNOWN A 99- TH C v ten. D. LEAK DETECTION t AUTOMATIC LINE LEAK DETECTOR 2 LINE TIGHTNESS TESTING3 IL ❑ MONRORING ❑ 99 OTHER V. TANK LEAK DETECTION I� 1 VISUAL CHECK ❑2 INVENTORY RECONCILIATION ❑ 3 VADOZE MONITORING ❑ 4 AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING 6 TANK TESTING INTERSTITIAL MONITORING ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER VI. TANK CLOSURE INFORMATION t. ESTIMATED DATE LAST USED (MO/OAY/YR) 2. ESTIMATED QUANTITY OF3. WAS TANK FILLED WITH 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 (PRINMO a SIGNATURE) DATE LOCAL AGENCY USE ONLY THE STATE I.D. NUMBER In nnluonccn mc rue cnun .N Ill EC ..,.. --- ..v AIDCnJ GCLVt� COUNTY # JURISDICTION # FACILITY # TANK # 4� ,i'e� y STATE 04 COUNTY L�f-1 ;1 / Li-- - PERMIT NUMBER �-�-PERMIT APPROVED BLY/DA.I TEI PERMIEXPIRATION DATE TI41C Cn OU un ICT 0C All AfiMau.rn n /!U -•. ----- - ----.. ••• rrrul.A1.UP1 - rUMM A, UNLESS A CURRENT FORMA HAS BEEN FILED. • • / � FOROCM&itS