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STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD //—� U�N '�® DERGROUND STORAGE TANK PERMIT APPLICATION - FORM B :�' ' �: �J O COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT ❑ 0 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ON SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 6 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVEDV A DBA OR FACILITY NAME WHERE TANK IS INSTALLED: <o yl( 7 I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN w 1.D.a O S. MANUFACTURED BY: U(C C. ]ATE INSTALLED(MOIDAYNEAR) U� D. TANK CAPACITY IN GALLONS: II.TANK COW ENTS IFA-I IS MARKED.COMPLETE ITEM C. A. 1 MOTOR VEHICLE FUEL ❑ A OIL a. C. ❑ 1.REGULAR AHOL e 0 DIESEL ❑ 6 AVIATINGAS ♦ GAS 2 PETROLEUM ❑ W EMPTY 1 PRODUCT ❑ 1E WMIU D Q 5 JET FUEL ❑ 7 METHANOL ',❑ S CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE 2 LEADED a 99 OTHER (DESCRIBE IN ITEM D. BELOW) O. IF(A1)IS NOT MARKED. ENTER NAME OF SUBSTANCE STORED C.A.S.4: III. TANK CONSTRUCTION MARKONE ITEM ONLY IN BOXES A.B.ANDC.AND ALLTHAT APPLIES IN BOX O AND A. TYPE OF ❑ 1 UBLE WALL F7 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM 2 SINGLE WALL ❑ A SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER B. TANK 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 0 FIBERGLASS ❑ s STEEL CUD WI FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM B 100% METHANOL COMPATIBLE WFRP (Prima(yTank) ❑ 9 BRONZY ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER ❑ I RUBBER LINED ❑ 2 ALKYD LNNG ❑ 0 EPDXY LINING ❑ a PHENOLIC LINING C.INTERIOR ❑ 5 GLASS LINING B UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER LINING IS LNING MATERIAL COMPATIBLE WITH I0 METHANOL? YES_ NO— D.CORROSION ❑ I POLYETHYLENE WRAP ❑ 2 COATING ❑ 0 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 EGUIPMENT INSTALLED(YEAR) IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND,BOTH IF APPLICABLE A SYSTEM TYPE A U TION A U 2 PRESSURE A U I GRAVITY A U 99 OTHER B. CONSTRUCTION A U LE ALL A U 2 DOUBLE WALL A U 0 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND A UEEL A U 2 STAINLESS STEEL A U 0 POLYVINYL CHLORIDE(PVC)A U A FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL WZOOATNG A U 8 100% METHANOL COMPATIBLE WFRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION ❑ 1 AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING ❑ INTHSMONITOTITIAL ❑99 OTHER V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ S VACqZE MONITORING ❑ a AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING ❑ 8 TANK TESTING ❑ 7 INTERSTITIAL MONITORING 1 NONE ❑ 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION 1.ESTIMATED DATE LAST USE (MOIDAYK R) 2.ESTIMATED OUANTITY OF 0.WAS TANK FILLED WITH YES ❑ SUBSTANCE REMAINING _GALLONS VERT MATERIAL THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY.AND TO THE BEST OF MY KNOWLEDGE IS TRUE AND CORRECT APPLICANrS NAME DATE (M9KIF0A5 Tueq LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY 9 JURISDICTION a FACILITY A TANK 0 A4er- 5 STATE I.DA ® =4 PERMIT NUMBER PERMIT APPROVED BYNATE PERMIT EXPIRATION DATE /a (9 C� FORM B (7.91) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. �� e-�