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v STATE OF CALIFORNIA 1 STATE WATER RESOURCES CONTROL BOARD �` •• UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM B COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. `"'•�• MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION VW7 PERMANENTLY CL SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ a AMENDED PERMIT ❑ 5 TEMPORARY TANK CLOSURE 9 TANK REMOVE DBA OR FACILITY NAME WHERE TANK IS INSTALLED: AKM 2Xb 41 I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A. OWNER'S TANK 1.0.9 2 8. MANUFACTURED BY: l).AI 1. C. GATE INSTALLED(MQOAYHEAR) ',O D. TANK CAPACITY IN GALLONS: lv r` IL TANK CONTENTS IF Al IS MARKED.COMPLETE ITEM C. V A. t MOTOR VEHICLE FUEL ❑ a OIL 8. D ❑ I9IRN REGULAR 06 3 DIESEL ❑ 8 AVIATKNI GAS ❑ 2 PETROLEUM ❑ SO EMPTY �1 PRODUCT 19PREMUM a GASA'OL 7 METHANOL ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2UNL DD ® 5 JET FUEL ❑ W OTHER (DESCRIBE IN ITEM D. BELOW) D. IF(A.1)IS NOT MARKED. ENTER NAME OF SUBSTANCE STORED l9 L C.A.S.9 III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.8.AND C.AND ALL THAT APPLIES IN BOX D AND A TYPE OF ❑ 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM 2 SINGLE WALL ❑ s SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER B. TANK ® I RARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ a STEEL CUA W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ e POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ S 1DD% METHANOL COMPATIBLE W/FRP (Pdmmy Twk) ❑ 9 BRONZE ❑ 10 GALVAN12ED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ a PHENOLIC LNNG C INTERIOR ❑ S GLASS LINING 6 UNLINED ❑ 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 ❑ 5 CATHODIC PROTECTION ❑ 91 NONE 95 UNKNOWN ❑ n OTHER E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED MAR) IV.PIPING INFORMATION CIRCLE AIFASOVEGROUNDORUIFUNOERGROUNO.BOTHIFAPPLCABLE A. SYSTEM TYPE A U 1 SUCTION AU2 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 1 BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)AU FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U S CONCRETE A U 7 STEEL V COATING A U S 100% METRANOL COMPATIBLE WrFRP PROTECTION A U 9 GALVANREO STEEL A U 10 CATHODIC PROTECTION A D 95 UNKNOWN A U ao OTHER D. LEAK DETECTION IeCri AUTOMATIC LINE LEAK DETECTOR gr2 LINE TIGHTNESS TESTING ❑ O MONITORING 7199 OTHER V.TANK LEAK DETECTION ❑IV1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VADOZE MONITORING ❑ a AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING IV 6 TANK TESTING ❑ 7 INTERSTITIAL MONITORING ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION 1.ESTIMATEP DATE,L,AST USED q 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH Y 'Z 7 6 SUBSTANCE REMAINING GALLONS INERT MATERIAL? E= No THIS FOWHAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANTS NAME (PRIxTED a slcxAnnn DATE Z+ LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS SOMPOISED OF THE F04R NUM RS BELOW COUNTY 9 JURISDICTION/ FA 9 TANK N / STATE LD.# 2 61 D PERMITNUMBER PLERMIT APPROVED BYiID E PERMIT EXPIRATION DAT Zl9 THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORM A,UNLESS A CURRENT FORM A HAS B FORMS (1291) I'" FI FILE THIS FORM WITH THE LOI.AGENCY IMPLEMENTING THE UNDERGROUND STORAGE"NK REGULA NS �, FCN00115G9