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ua e cp STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B o ��t1ipAM� COMPLETE A SEPARATE FORM FOR VM TANK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT Der 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED O ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ S TANK REMOVED S DBA OR FACILITY NAME WHERE TANK IS INSTALLED: (4 u4u� Ln� I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A. OWNER'S TANK I.D.• S B. MANUFACTURED BY: C. DATE INSTALLED (MO/DAV/YEAR) D. TANK CAPACITY IN GALLONS: AklvCnkffcNTa COMP TEITEMC II. I IFA -1 A ❑ 1 MOTOR VEHICLE FUEL 4 OIL B. C. ❑ 1e REGULAR 3 DIESEL ❑ 6 AVIATION GAS ❑ 2 PETROLEUM 60 EMPTY ❑ 1 PppOODUCT ❑ 1I PREMIUM UNLEADED 4 GASAHOL ❑ 7 METHANOL ❑ 5 JET FUEL ❑ 3 CHEMICAPRODUCT ❑ 95 UNKNOWN / ❑L /2 WASTE ❑ 2 LEADED ❑ 99 OTHER (DESCRIBE IN ITEM D. BELOW) D. IF (A.1) 19 NOT MARKED. ENTER NAME OF SUBSTANCE STORED � tG D � C. A. S. #: 1 Tiny nnAIQTo"V TInM P eunc eun.11 TWAT 4PPI IFS IN AnYn A. TYPE OF❑ 1 UBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN ATI PRESSURE A U t/ECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER SYSTEM 2 SINGLE WALL 1 SINGLE WALL A U 2 DOUBLE WALL A U Eijol BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/ FIBERGLASS REINFORCED PLASTIC B. TANK MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 6 1009: METHANOL COMPATIBLE W/FflP (PAmmyTm61) ❑ 9 BRONZEI❑—I 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER F--]1 RUBBER LINED '� jILKYD LINING F-13 EPDXY LINING ❑ 4 PHENOLIC LINING C. INTERIOR ❑ 6 GLASS LINING L^I UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER LINING 6 CONCRETE A U 7 STEEL W/ COATING A U B 100% METHANOL COMA BLEW RP PROTECTION IS LINING MATERIA COMPATIBLE WITH 100%METHANOL7 YES_ NO— 9 GALVANIZED STEEL D. CORROSION = 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER IV. PIPING INFORMATION CIRCLE A IFABOVEGROUNDOR U IF UNDERGROUND, BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION ATI PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION U 1 SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 90 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 B 100% METHANOL COMA BLEW RP PROTECTION A U 9 GALVANIZED STEEL A U /0 CATHODIC PROTECTION A U 95 UNKNOWN A OTHER D. LEAK DETECTION ERb ❑ 1 AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING ❑ 31MMONR RINGmAL ❑ 99 OTHE 9 . 1 e'. V. TAN LEAK DETECTION ✓ i dr � 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 147A DATE LAST USED (MO/DAY/YR) 2 ESISIMAATEO NCE EMAIININGF GALLONS 3 WINERT MATEFILLED RIAL 7H YES ❑ NO ❑ THIE FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANTS NAME DATE IPRINTEO 6 SIGNATURE) LOCAL AGENCY USE ONLY THE STATE I.D. NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY# TANK III STATE I -D.# s-3 10 PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE FORM B (490) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION - FORM A, UNLESS A CURRENT FORM A HAS BEEN FILED. FOR9031B-R4