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• pA cecoY .. °o STATE OF CALIFORNIA ^+ STATE WATER RESOURCES CONTROL BOARD i UNDERGROUND STORAGE TANK PERMIT APPLICATION . FORM B I. TANK DESCRIPTION COMPLETE ALL ITEMS-- SPECIFY IF UNKNOWN A. OWNER'S TANK I.D.# COMPLETE A SEPARATE FORM FOR EACH T K SYSTEMS B. MANUFACTURED BY: 4 (L ' MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT5 ❑ 2 WASTE CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ON SITI ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: 2. "3 If S Sic ��ivi7 6 CONCRETE A U �p� p I. TANK DESCRIPTION COMPLETE ALL ITEMS-- SPECIFY IF UNKNOWN A. OWNER'S TANK I.D.# (J B. MANUFACTURED BY: 4 (L C. DATE INSTALLED (MO/DAYA'EAR) 11-75- D. TANK CAPACITY IN GALLONS: tlC�d O ILTANKCONTENTS IFA -11S MARKED,COMPLETE ITEM C. A 1 MOTOR VEHICLE FUEL ❑ 4 OIL B.C. ❑ 1S REGULAR ❑ 3 DIESEL ❑ 6 AVIATIONGAS ❑ 4 GASAHOL F--12 PETROLEUM ❑ M EMPTY 1 PRODUCT �1b PREMIUM ❑ 7 METHANOL UNLEADED ❑ 5 JET FUEL ❑ 3 CHEMICALPRODUCT ❑ 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 BOXESA. B, AND C, AND ALL THAT APPLIES IN BOX A. TYPE OF 11DOUBLE WALL F-]3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM �❑I LG —2—SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER 1 SINGLE WALL L�ol BARE STEEL ❑ 2 STAINLESS STEEL F--]3 FIBERGLASS ❑ 4 STEEL CLAD W/ FIBERGLASS REINFORCED PLASTIC B. TANK MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ S 100% METHANOL COMPATIBLE W/FRP (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 96 UNKNOWN ❑ 99 OTHER 6 CONCRETE A U ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING C. INTERIOR ❑ 5 GLASS LINING La-6—UNLINED 96 UNKNOWN ❑ 99 OTHER LINING ❑ 1 AUTOMATIC LINE LEAK DETECTOR En -2 LINE TIGHTNESS TESTING ❑ 3INTERSTITIALE:]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 5 UNKNOWN ❑ 99 OTHER IV. PIPINU INYUHMAI WN CIRCLE A IFABOVEGROUNDOR U IF UNDERGROUND, BOTH IF APPLICABLE A. SYSTEM TYPE A(V1 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 5 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 W/COATING A U S 1001A METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION05 UNKNOWN A U 99 OTHER D. LEAK DETECTION ❑ 1 AUTOMATIC LINE LEAK DETECTOR En -2 LINE TIGHTNESS TESTING ❑ 3INTERSTITIALE:]99 OTHER MONITORING V. TANK LEAK DETECTION ❑ 1VISUAL CHECK INVENTORY RECONCILIATION ❑ 3 VAPOR MONITORING ❑ 4 AUTOMATIC TANK GAUGING ❑ 5 GROUNDWATER MONITORING �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 SUBSTANCE REMAINING GALLONS INERTMATERIAL7 YES ❑ NO ❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANT'S NAME DATE (PRINTED 8 SIGNATURE( LOCAL AGENCY USE ONLY THE STATE I.D. NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY# TANK# SvwPlz3 STATE LD.# ® U q PERMITNUMBER PERMIT APPROVED BV/DATE PERMIT EXPIRATION DATE-, -2-5-57 FORM B (9-90) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION • FORM A, UNLESS A CURRENT FORM A HAS BEEN FILED. 10RIG413 RA • 0 A___ '-�?