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iSTATEOFCALIFORMAa . STATE WATER RESOURCES CONTROL BOARD f UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM B e!a COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. RK ONLY 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION 7 PERMANENTLY CLO SP ONE REM ❑ 2 INTERIM PERMIT ❑ A AMENDED PERMIT ❑ a TEMPORARY TANK CLOSURE ' A TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: R e- 2A\ab I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A. OWNER'S TANK I.D.a 4 B. MANUFACTURED BY: C. DATE INSTALLED(MODAYMEAR) 1� D. TANK CAPACITY IN GALLONS: U II.TANK CONTENTS IFA•11SMARKED.COMPLETE ITEM C. A. 1 MOTOR VEHICLE FUEL ❑ A OIL 8. O ❑ Is REGULAR 3 DIESEL ❑ 6 AVIATION GAS ❑ 2 PETROLEUM EDW EMPTY ® 1 PRODUCT PREMIUM A GASAHOL 7 METHANOL CD3 CHEMICAL PRODUCT [—] BS UNKNOWN ❑ 2 WASTE � 10 UNLEADED 5 JET FUEL ❑ ❑ 2 LEADED 99 OTHER (DESCRIBE N ITEM D. BELOW) O. F(A1)IS NOT MARKED. ENTER NAME OF SUBSTANCE STORED C.A.S a 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 EXTERKR LINER ❑ 95 UNKNOWN SYSTEM 2 SINGLE WALL ❑ A SECONDARY CONTAINMENT (VAULTED TANK ❑ 99 OTHER 8. TANK ® 1 BARE STEEL 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ A STEEL CLAD W/F113ERCLAW REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 6 100% METHANOL COMPATIBLE W/FRP (PrimaryTank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ M OTHER ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ A PHENOLIC LINING C INLIN IIOR ❑ 5 GLASS LINING ® 6 UNLINED ❑ 95 UNKNOWN ❑ W OTHER IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL 7 YES— NO_ D.CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ A FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 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 1 SUCTION A(&>2 PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION AU1 SMILE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND A U 1 BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)AU04 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL W/COATING A U 6 1O0% METHANOL COMPATIBLEW/FRP PROTECTION A U 9 GALVANRED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION i AUTOMATIC LINE LEAK DETECTOR R:r2 LINE TIGHTNESS TESTING ❑ MdIR013NG ❑ W OTHER V.TANK LEAK DETECTION CI 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VADOZE MONITORING ❑ A AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING 6 TANK TESTING ❑ 7 INTERSTITIAL MONITORING ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION I.ESTIM AT/E LAST UB Y R) 2.ESTIMATED QUANTITY OF 1 WAS TANK FILLED WITH 7 9 SUBSTANCE REMAINING GALLONS INERT MATERIAL? YES ❑ NO 7-Hd F RM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, 1S TRUE AND CORRECT APPLICANTS NAME LL\\ DATEQ IPIiK1Eo a aI.KATUPEI \�I\I 1 cL 1S' LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS OMPOSE2 OF THE FOU NUMBWM BELOW COUNTY 9 JURISDICTION k ITY X TANK 9 STATE I.D.# mlITT� O PERMIT NUMBER PERMIT APPROVED BYIDATE PERMIT EXPoMTgN TE n ^ THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORM A,UNLESS A CURRENT FORMA AS BEEN FILED. ` FILE THIS FORM WRN THE LOC"' AGENCY IMPLEMENTING ING THE UNDERGRSTORAK R GULATpNS CORM 9 ;12911 fCRomN6RN