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o - STATEOFCAUFORNA STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM MARK ONLYJAI 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED ONSITI ONE ITEM �L-J-1 2 INTERIM PERMIT ❑ 4 AMENDEDERMIT P 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED O' DBA OR FACILITY NAME WHERE TANK IS INSTALLED: 2_--Z5 CDl)nmzy B 57(y_j-<Jr)m ❑ 5 CONCRETE 1 AINK UtZA;KIY I WN COMPLETE ALL ITEMS -- SPECIFY IF UNKNOWN A. OWNER'S TANK I.D.# ` B. MANUFACTURED BY: V C. DATE INSTALLED (MO/DAYIYEAR) Ui< D. TANK CAPACITY IN GALLONS: ILTANK NTENTS IFA -11S MARKED. COMPLETE ITEM C. A. 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C• UNLEADED ❑ 3 DIESEL ❑ 6 AVIATIONGAS 2 PETROLEUM❑ 80 EMPTY ❑ 1 PflODUCT 1b PflEMIUM ❑ 4 GASAHOL ❑ 7 METHANOL ❑ 3 CHEMICALPRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE UNLEADED 2 LEADED ❑ 5 JETFUEL ❑ 4 STEELCLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 99 OTHER (DESCRIBE IN ITEM D. BELOW) D. IF (A.1) IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C. A. S. 0 III. TANK CONSTRUCTION MARV nuC.TCu nul v lu onvCen o .V ImI nun Al r A. TYPE OF�❑ 11 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM U 2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER S. TANK 1 BARE STEEL F72 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEELCLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP (PrlmaryTank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER 6 CONCRETE A U ❑ 1 RUBBER LINED❑ 2 ALKYD LINING ❑ 3 EPDXY LINING E:]4 PHENOLIC LINING C. INTERIOR LINING F-1 5 GLASS LINING [2-6— UNLINED ❑ 95 UNKNOWN99 ❑ OTHER D. IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO— DETECTOR [::]2 LINE TIGHTNESS TESTING ❑ 31 ERS L D. CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION FT3141' NONE ❑ 95 UNKNOWN ❑ 99 OTHER IV. PIPING INFORMATION CIROIF AIPe9nvFnonuunnoII nluncanonll,' R se,, .e,, A. SYSTEM TYPE A U 1 SUCTION AaLb PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION AU 1 SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND A141 1 BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE (PVC) A U 4 FIBERGLASS PIPE CORROSION Ay 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL W/ COATING A U 8 100% METHANOL COMPATIBLE W/FRP PROTECTION A U 9GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN p U 99 OTHER D. LEAK DETECTION 1 AUTOMATIC LINE LEAK DETECTOR [::]2 LINE TIGHTNESS TESTING ❑ 31 ERS L 99 OTHER ❑ MONBOgING TA\IV 1 LAV P 11T MTI^Ikl •. 1 nl\I� LCA\IA YL1 CV I IVIY ❑ 1 VISUAL CHECK 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 F VI. TANK CLOSURE INFORMATION 1. ESTIMATED DATE LAST USED (MO/DAYNR) 2. ESTIMATED QUANTITY OF 3. WAS TANK FILLED WITH YES ❑ NO F7SUBSTANCE REMAINING GALLONS INERT MATERIAL] THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE. IS TRUE AND CORRFr.T APPLICANTS NAME (PRINTED A SIGNATURE) DATE LOCAL AGENCY USE ONLY THE STATE I.D. NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY # JURISDICTION # FACILITY # TANK # STATE LDA® = I -I - I I �7Tz� T�I�rn 'ERMITNUMBER PERMIT APPROVED BY/DATE ��PERMMIT EXPIRATION �LDATE _JL.1JJ FORM B (9.90) I MI5 VUHM MUST Be ACCOMPANIED BY A PERMR APPUCATION • FORMA, UNLESS A CURRENT FORMA HAS BEEN FILED. FOROaifBR4 1