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STATEOFCAUFORMA 1 STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION-FORM B 6a -_ COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED ITE ONE REM ❑ 2 INTERIM PERMIT ❑ a AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE 8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: Odiceb 9 Ir I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A OWNERS TANK I.D.8 2- B. MANUFACTURED BY: Lwuwu �nl';�Nq�7 C. DATE INSTALLED(MO/DAYNEAR) ',� D. TANK CAPACITY IN GALLONS: to /1 ILTANKCONTENTS IFA-1 IS MARKED.COMPLETE ITEM C. V A, 1 MOTOR VEHICLE FUEL ❑ a OIL B. C. ❑ 1a REGULAR 3 DIESEL F-16 AVIATION GAS ❑ 2 PETROLEUM ❑ 80 EMPTY �I PRODUCT 111 PREMIUM A GASAIOL 7 METHANOL UNLEADED S JET FUEL ❑ ❑ 3 CHEMICAL PRODUCT ❑ B5 UNKNOWN ❑ 2 WASTE 2 LEADED 99 OTHER (DESCRIBE IN ITEM D.BELOW) D. IF(Al)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED I#IL C.A S.e: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.B.AND C.AND ALL THAT APPLES IN BOX D AND A. TYPE OF ❑ 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM 2 SINGLE WALL ❑ a SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER B. TANK ® I BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ a STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE WIFRP (PnmaryTMlk) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 00 OTHER ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ A PHENOLIC LINING C.INTERIOR ❑ 5 GLASS LINING 8 UNLINED LINING / ❑ 95 UNKNOWN ❑ 99 OTHER IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL 7 YES_ NO D.CORROSION ❑ I POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ A FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ S CATHODIC PROTECTION ❑ 91 NONE 95 UNKNOWN ❑ 99 OTHER E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND.BOTH IF APPLICABLE A. SYSTEM TYPE A U I SUCTION AQ)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 A U 95 UNKNOWN A U 90 OTHER C. MATERIAL AND A U I BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVL)A(E). FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL 0 COATING A U 8 100% METHANOL COMPATIBLE WFRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 85 UNKNOWN A U 99 OTHER D. LEAK DETECTION tMI AUTOMATIC LINE LEAK DETECTOR 2r2 UNE TIGHTNESS TESTING ❑ M~WORNG '❑yy OTHER V.TANK LEAK DETECTION F-7, 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VAOOZE MONITORING ❑ A AUTOMATIC TANK GAUGING ❑ S GROUND WATER MONITORING "Qr8 TANK TESTING ❑ 7 INTERSTITIAL MONITORING ❑ 91 NONE ❑ 95 UNKNOWN ❑ 00 OTHER VI.TANK CLOSURE INFORMATION 1.ESTIMATED DATE LAST USED A R 2.ESTIMATED OUANTRY OF 3.WAS TANK FILLED WITH d� SUBSTANCE REMAINING _GALLONS NERTMATERIAL? YES a NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANTS NAME \ DATE (PmN As ATUR q LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS 6POSED OF THE FO R NUM RS BELOW STATE I.D.# COUNTY 9 JURISDICTION 8 k FA LLTY 8 TANK 800 ® 1A p ? / I O 1 b (r IIAI / A PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE O THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. FORM 9 (1291) FILE THIS FORM WITHTHE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS � � Fp10m1LRf