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STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B a �° COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. , No� MARK ONLY 1 NEW PERMIT F-]3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMAN NTLY E D ON SIT ONE ITEM I?I - 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK R OVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: -j 01 Q / , &—A -AIV % �i/ , �� C��_r t I TAAII[ nFCCRIPTInN cnMPI PTF At I ITEMS -- SPECIFY IF UNKNOWN A. OWNER'S TANK I. D. # B. B. MANUFACTURED BY: 0 C. DATE INSTALLED(MO/DAYNEAR) D. TANK CAPACITY IN GALLONS: 11 TA\IV /%ALITCAITC LA AovCn I ^KAW1 CTC ITCV !`. 1 MOTOR VEHICLE FUEL 4 OIL B. C. ❑ 1aREGULARUNLEADED ❑ 3 DIESEL ❑ 6 AVIATION GAS ❑ 4 ❑ 2 PETROLEUM ❑ 80 EMPTY ❑ 1 P DUCT ❑ 1b PREMIUM JET FUEL ❑ 7 METHANOL UNLEADED ❑ 5 JET FUEL ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN 2 WASTE ❑ 2 LEADED OTHER (DESCRIBE IN ITEM D. BELOW) D. IF (A.1) IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C. A. S. #: III TA AIV f nKICTRI l(`_TIf)N kAAOIC nuc ITPU nNI V w RnXP3 A. R- AND C. AND ALL THAT APPLIES IN BOX D A. TYPE OF 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM ❑ 2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (V LTED TANK) ❑ 99 OTHER 2 PRESSURE AM F-]1 BARE STEEL F-12 STAINLESS STEEL 3 FIBERGLASS 7]4 STEEL CLAD W/ FIBERGLASS REINFORCED PLASTIC B. TANK MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE F__]7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER C. MATERIAL AND ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING C. INTERIOR ❑ 5 GLASS LINING ❑ 6 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER LINING 6 CONCRETE A U 7 STEEL W/ COATING A U 8 100% METHANOL COMPATIBLE W/FRP PROTECTION A U IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO 10 CATHODIC PROTECTION D. CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER IV. DINING INI-UHMAI IWN CIRCLE A IF ABOVE GROUND OR U IF UNUt RGROUN1 O I H IF ArrucAlA.t A. SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE AM 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 A U 1 BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE (PVC) A U 4 FIBERGLASS PIPE C. MATERIAL AND CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL W/ 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 D. LEAK DETECTION ❑ 1 AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING ❑ 3 INTERSTITIAL MONITORING [:]99 OTHER V. TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VAPOR MONITORING 4 AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING ❑ 6 TANK TESTING ❑ 7 INTERSTITIAL MONITORING ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER VI. TANK CLOSURE INFORMATION 1. ESTIMATED DATE LAST USED (MO/DAY/YR) 2. ESTIMATED QUANTITY OF 3. WAS TANK FILLED WITH YES ❑ 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 DATE (PRINTED A SIGNATURE) LOCAL AGENCY USE ONLY THE STATE I.D. NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY # JURISDICTION NTANK ' STATE I. D.# ❑� PERMITNUMBER PERMIT APPROVED BY/DAT /� V V P IT EXPIRATION DATE FORM B (9-90) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION -FORMA, UNLESS A CURRENT FORMA HAS BEEN FILEDgA? F 00346-R4 0 0 A4�' M