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STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD e<*,V UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B v; C e I � a> COMPLETE A SEPARATE FORM FOR EAC K SYSTEM 4 EDSA K ONLY ❑ 1 NEW PERMIT ❑ 7 RENEWAL PERMIT 6 CHANGE OF INFORMATION E REM ❑ 2 INTERIM PERMIT 6 AMENDED PERMIT a 7 PERMANENTLY CLOSED ON SITE ❑ ❑ 6 TEMPORARY TANK CLOSURE 8 TANK REMOVED OR FACILITY NAME WHERE TANK IS INSTALLED: I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A. OWNER'S TANK I.D.# �/ B. MANUFACTURED BY: C. DATE INSTALLED(MOIDAY/YEAR) v(IL' 0. TANK CAPACITY IN GALLONS: d0 n IL TANKC NTS IFA4 ISMARKED,COMPLETE ITEM C. A. 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. / C. ❑ 1iUNLEAOED 3 DIESEL ❑ e pVMTKkI GAS ❑ 2 PETROLEUM ❑ s0 EMPTY E:7 Pwo= ❑ 10 Pjl�EE IUM 4 L �,IUNLEADED O 5 JETFUEL ❑ 7 METHANOL ❑ 3 CHEMICAL PROOl1CT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 USAGE O ❑ 99 OTHER (DESCRIBE IN ITEM D. BELO" 0. IF(A.1)IS NOT MARKED, ENTER NAME OFSUBSTANCE STORED C.A S.s: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.8,AND C.AND ALL THAT APPLIES IN 80X0 AND A. TYPE OF n I BOUS E WALL El ER 3 SINGLE WALL WITH EXTERIOR LIN ,LSI/2 ❑ BS UNKNOWN SYSTEM S E WALL ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER B. TANK 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEELCLAO W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 8 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 1001 METHANOL COMPATIBLE W/FRP (PHRmyTmk) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER ❑ / RUBBER LINED ❑ 2 ALKYO LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING C.INTERIOR ❑ 5 GLASS LINING UNLINED ❑ 95 UNW40WN ❑ 99 OTHER IS LINING MATERIAL COMPATIBLE WITH 1000%METHANOL) YES_ NO_ D.CORROSK)N ❑ 1 POLYETHYLENE WRAP [:] O�,2 TING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODAL:PROTECTION (—_�S1/NONE ❑95 UNKNOWN ❑ 99 OTHER E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED MAR) OVERFILL PREVENTION EQUIPMENT 04TALLED(YEAR) IV.PIPING INFORMATION CIRCLE A IFASOVEGROUNDOR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A UDR S. CONSTRUCTION A SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND A U qLURESTEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A U 4 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEELW/COATING A U 8 100% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODAL;PROTECTION A U 95 UNKNOWN A U 90 OTHER D. LEAK DETECTION ❑ 1 AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING ❑ MONRORNG ❑ 99 OTHER V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VADOZE MONITORING ❑ 4 AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING ❑ 8 TANK TESTING ❑ 7 INTERSTITIAL MONITORING ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION I.ESTIMATED DATE LAST USED(MO/DAY/YR) 2.ESTIMATED OUANTITY OF REMA NTNG GALLONS 3.WAS TAN MATED WITH yE3 ❑ NO yS 6- SUBSTANCE ERJ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANT'S NAME DATE (PRINTED!SIGNATURE) LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# �-�-FTA-�CI,L�IT�Y$ TANK• ST/9JAJ�/ STATE I.D.# 131F? I I l�J �L7 fT-I�-rm PERMIT NUMBER PERMIT APPROVED BY/DATE PERMITEXPIRATIO DAr� /,- �Ylf 2_ Cp FORM B (7-91) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. �� fOA4048A5