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'Q60VN STATE OF CALIFORNIA co STATE WATER RESOURCES CONTROL BOARD i �, ° UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B �e �„ oa COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. °�I,.P"��A , MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ON SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED �/ DBA OR FACILITY NAME WHERE TANK IS INSTALLED: Z 3 D. IF (A.1) IS NOT MARKED. ENTER NAME OF SUBSTANCE STORED C. A. S. #: ❑ 8 100% METHANOL COMPATIBLE WIFRP V17 I TAAIV nCQf'OIOTv1M rn 11 ITFUR_ 9PFnIFV IFIINKNGWN A. OWNER'S TANK I.D.# (%73 77 B. MANUFACTURED BY: 6!7`,e// 771 C. DATE INSTALLED (MO/DAY/YEAR) 7 D. TANK CAPACITY IN GALLONS: 11 TAKIvrnMTPMTQ ICA ,,e NAoKFnnt UPIFTFITPMr:. A. t MOTOR VEHICLE FUEL ❑ 4 OIL B. C. UNLEADED Gt LAR❑ ❑ 3 DIESEL ❑ 6 AVIATION GAS 4 GASAHOL ❑ 2 PETROLEUM ❑ 80 EMPTY 1 PRODUCT ❑ 1b PREMIUM ,-UNLEADED ❑ ❑ 7 METHANOL 5 JET FUEL ❑ 3 CHEMICAL PRODUCT ❑ 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. #: 111 TAaly rnAI42T0I1rTInlJ AAADVnklCITCUnAdIVIMnnYrRA P ANnC. ANn All THATAPPLIES INBOXD .... ....... --.._...------- ❑ I DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN A. TYPE OF SYSTEM SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER B. 1 BARE STEEL ❑ 2 STAINLESS STEEL F-13 FIBERGLASS ❑ 4 STEEL CLAD W/ FIBERGLASS REINFORCED PLASTIC B. TANK MATERIAL ❑ s CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE WIFRP (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER A U ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING C. INTERIOR ❑ 5 GLASS LINING �QNLINED F-]95 UNKNOWN ❑ 99 OTHER LINING s� CORROSION A U 5 ALUMINUM IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO— A U 7 STEELW/COATING A U ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING❑ 3 V L WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC D. CORROSION PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE 95 UNKNOWN ❑ 99 OTHER III DIDIMn IMFnRUATION r:IRn1F A IF ARnVF GROUND OR U IF UNDERGROUND. BOTH IF APPLICABLE A. SYSTEM TYPE U 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 AeV5 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 STEELW/COATING A U 9 100% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 NKNOWN A U 99 OTHER D. LEAK DETECTION ❑ I AUTOMATIC LINE LEAK DETECTORINE TIGHTNESS TESTING ❑ 3INTERSTITIAL [-]99 OTHER I TAaly I CAV nCTCrTIAM ' ❑,1A VS `CHECKv - 2 INVENTORY RECONCILIATION ❑ 3 VAPOR MONITORING ❑ 4 AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING TANK TESTING ❑ 7 INTERSTITIAL MONITORING ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER 1. ESTI MATED DATE LAST USED(MO/DAY/YR) 2. ESTIMATED QUANTITY OF 3. WASTANKFILLED WITH SUB STA NCE REMAINING GALLONS INERT MATERIAL? YES ❑ NO❑ THIS "ORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST Uh MY KNOWLEDGE, IS TRUE Arvu cue APPLICANTS NAME DATE PRINTED A SIGNATURE) nrAl ArFNCV IIRF ONLY THE STATE I.D. NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW -?ECT COUNTY# JURISDICTION# FACILITY# TANK# wypr Zh STATE I.D.# 9, o PERMITNUMBER PERMITAPPROVED BY/DATE PERMIT EXPIRATION DATE�j —�/�Z ^.✓ FORM B (9-90) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION - FORM A, UNLESS A CURRENT FORM A HAS BEEN FILED. FOROODMI/Ra 1 l/