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STATE OF CALIFORNIA a STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM BCOMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM MARK ONLY ❑ 1 NEW PERMIT 3 RENEWAL PERMIT5 CHANGE OF INFORMATION E:] 7 PERMANENTLY ONE REM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE L] 8 TANK REMOVED 0191 ONSITE 09 DBA OR FACILTIY NAME WHERE TANK IS INSTALLED: I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A OWNERS TANK I.D.# O B. MANUFACTURED BY: u C. DATE INSTALLED(MO/DAYNEM) &7C D. TANK CAPACITY IN GALLONS: n II.TANK CONTENTS IFA-11SMARKED,COMPLETE REM C. cW A. i MOTOR VEHICLE FUEL ❑ 4 OIL B. �- 0. EER'2 1aUNLEA R 3 DIESEL ❑ e AVIATK7N GAS ❑ 2 PETROLEUM ❑ BO EMPTY a T PRODUCT 1bJF IUM 4 ��L ❑ 7 METHANOL LEADEO Q 5 JET FUEL❑ 3 CHEMICAL PRODUCT ❑ 96 UNIWOWN ❑ 2 WASTE LEADED ❑ 90 OTTER (DESCRIBE IN REM D. BELOW) D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A S.4: III. TANK CONSTRUCTION MARK ONE ITEM ONLY M BOXES A BAND C.AND ALL THAT APPLIES IN BOX A. TYPE OF ❑ 1 BLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UN1040WN SYSTEM 2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER B. TANK SARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD Wl FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 8 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP (PAmwy Tmk) ❑ 0 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED ❑ 2 AL LINING ❑ 3 EPDXY LINING E] 4 PHENOLIC LINING C.INTERIOR F-15 GLASS LINING UNLINED ❑ 95 UNKNOWN90 OTTER LINING ❑ IS LINING MATERIAL COMPATIBLE WITH 100%METRANOL7 YES_ NO— D.CORROSION ❑ 1 POLYETHYLENE WRAPn 2 (pAYINO ❑ 3 VINYL WRAP E-] 4 FIBERGLASS REINFORCED PLASTIC PROTECTION F-1 5 CATHODIC PROTECTION 1 NONE ❑ 95 UNKNOWN O 90 OTHER IV.PIPING INFORMATION RCHE A IFABOVEGROUNDOR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U SUC A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER S. CONSTRUCTION A LE A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 96 UNKNOWN A U 99 OTHER C. MATERIAL AND A U < EST L A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A U 4 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U B CONCRETE A U 7 STEEL V#COATINO A U 8 100% METHANOL COMPATIBLE W/FRP 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 ❑ J ROT R MGAL ❑90 OTHER V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK 2 INVENTORY RECONCILIATION ❑ 3 VAPOR MONITORING❑ 4 AUTOMATIC TANK GAUGING❑ 5 GROUND WATER MONITORING ❑ 6 TANK TESTING ❑ 7 INTERSTITIALMONrTORING ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION 1.ESTIMATED DATE LAS�SSED)MOA)AWYR) 2 ESTIMATED WANTRV OF 3.WAS TANK FILLED WITH / SUBSTANCE REMAINING GALLONS INERTMATERIAL7 YES [:] NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANT'S NAME DATE Hvw6re0 a sicrvM LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY# TANK# STATE I.D.# ® 14(13 171 o I I I 1 110 / PERMIT NUMBER PERMIT APPROVED BYIDATE PERMIT EXPIRATION DATE FORMS(9-M THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. FORMS-24 l��