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suunces STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD } UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B 3 � ua��• � a COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. C'41 iwl MARK ONLY 5111 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ONSITE ONE ITEM 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: LAT { I a -V C M-EV lz g I I. TANK DESCRIPTION COMPLETE ALL ITEMS – SPECIFY IF UNKNOWN A. OWNER'S TANK I. D. # ( B. MANUFACTURED BY: `ice 17 C. DATE INSTALLED (MO/DAY/YEAR) `u Ly r �y D. TANK CAPACITY IN GALLOONS: II, TANK CONTENTS IFA -1 IS MARKED, COMPLETE ITEM C A. �' 1 MOTOR VEHICLE FUEL ❑ 4 OIL B.❑GAS O• hl la REGULAR3 DIESEL 6 AVIATION 2 PETROLEUM ❑ 80 EMPTY 1 PRODUCT 4 GASAHOL r�� 1b PREMIUM L ❑ r 7 METHANOL 0 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 UNLEADED ❑ 5 JETFUEL J LEADED ❑ 99 OTHER (DESCRIBE IN ITEM D. BELOW) D. IF (A.1) IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S.#: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A, B, AND C, AND ALL THAT APPLIES IN BOX D AND E A. TYPE OF F;?4 1 DOUBLE WALL ❑ 3 SINGLE WALL W17H EXTERIGR LINER ❑ 95 UNKNOWN SYSTEM ❑ 2 SINGLE WALL 4 SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER B. TANK F7 1 BARE STEEL 0 2 STAINLESS STEEL ❑ 3 FIBERGLASS tR 4 STEEL CLAD WI FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE WIFRP (Primary Tank) ❑ 9 ,BRONZE 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER P❑ 1 RUBBER LINED C. INTERIOR ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING 4 PHENOLIC LINING ❑ 5 GLASS LINING 6 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER IS LINING MATERIAL COMPATIBLE WITH 100'Y METHANOL? YES— NO— D. CORROSION F—] 1 POLYETHYLENE WRAP P❑ 2 COATING PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE E. SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED (YEAR) ❑ 3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC 95 UNKNOWN ❑ 99 OTHER OVERFILL PREVENTION EQUIPMENT INSTALLED (YEAR), _ 1V. PIPING INFORMATION CIRCLE A IFABOVEGROUNDOR U IF UNDERGROUND, BOTH IFAPPLICABLE A. SYSTEM TYPE AIQ 1 SUCTION A QC2 PRESS -URI A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A ld 1 SINGLE WALL A 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) A U 4 FIBERGLASS PI CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL W/ COATING A U B 100% METHANOL COMPATIBLE WIFRP 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 ❑ 3 MONITORING ❑ 99 OTHER V. TANK LEAK DETECTION 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VADOZE MONITORING 4 AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING ❑ 6 TANK TESTING ❑ 7 INTERSTITIAL MONITORING ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER VI. TANK CLOSURE INFORMATION 1. ESTIMATED DATE LAST USED iIMOIDAY/YR) 2. ESTIMATED QUANTITY OF 3. WAS TANK FILLED WITH SUBSTANCE REMAINING GALLONS INERT MATERIAL 7 YES ❑ NO ❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDC3E IS TRUE AND CORRECT APPLICANTS NAME (PRINTED S SIGNATURE)— — A ' _ 1 r\ DATE - I 5 ► 7-q5 LOCAL AGENCY USE ONLY THE STATE I.D. NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW STATE P.D.# COUNTY # JUHISDICTION # FACILITY # ,� TANK # FT7 �❑ ,� PERM 17 NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE FORM 6 (7-91) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION • FORMA, UNLESS A CURRENT FORMA HAS BEEN FILED. 0 FOR0034B-115 •