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STATE OF CALIFORNIA •,4 s STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION• FORM B "�"� b . . ; COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM MARK ONLY ® 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 15 CHANGE OF INFORMATION E37 PERMANENTLY CLOSED ONSITE / ONE REM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT [:Ie TEMPORARY TANK CLOSURE ❑6943 6 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: ' u _1r. � S.51 �1 pTL�- qcl I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A. OWNER'S TANK LD.t B. MANUFACTURED BY: '-r TIAL_ Wy1Tl`INMIa sJ7 C. DATE INSTALLED IMO(DAY/VEAR) D. TANK CAPACITY IN GALLONS: ILTANKCONTENTS IFA-11S MARKED.COMPLETE ITEM C. A. ®' 1 MOTOR VEHICLE FUEL ❑ q OIL $, C 1a REGULAR 3 DIESEL ® UNLEADED ❑ 6 AVIATION GAS ❑ 2 PETROLEUM ❑ 60 EMPTY 1 PRODUCT ❑ lb PREMIUM 4 GASAHOL ❑ 7 METHANOL ❑ 3 CHEMICAL PRODUCT 95 UNKNOWN 2 WASTE UNLEADED ❑ 5 JET FUEL ❑ 2 LEADED ❑ p9 OTHER (DESCRIBE IN ITEM D. BELOW) D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S.a: III. TANK CONSTRUCTION MARKONE ITEM ONLY IN BOXES A,B.ANDC.ANDALLTHATAPPLIES INBOXDANDE A. TYPE OF 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM ❑ 2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER B. TANK ❑ 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS �, 4 STEEL CLAD WI FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 6 IDD% METHANOL COMPATIBLE W/Fgp (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 25 UNKNOWN ❑ W OTHER F--11 RUBBER LINED ❑ 2 ALKYD LWING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING C I LINING R ❑ 5 GLASS LINING ffi 6 UNLINED ❑ 95 UNKNOWN ❑ 98 OTHER IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES Z NO— D.CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE 95 UNKNOWN ❑ 99 OTHER E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR) 1 OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) 1�79�1 IV.PIPING INFORMATION CIRCLE A IFABOVEGROUNDOR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION A OP2 PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL A I# 2 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)A200 4 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL W/COATING A U 6 100% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U BS UNKNOWN A U W OTHER D. LEAK DETECTION ❑ 1 AUTOMATIC LINE LEAK DETECTOR ❑'2 LINE TIGHTNESS TESTINGTERSTIT 17— MONrtORING ❑ W OTHER V.TAN LEAK DETECTION 1 $UAL CHECK 2 VENTORY RECONCILIATION ❑ 3 VADOZE MONITORING 4 AUTOMATIC TANK GAUGING O 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(MO/DAY/YR) 2.ESTIMATED QUANTITY OF 3,WAS TANK FILLED WITH SUBSTANCE REMAINING GALLONS INERT MATERIAL? YES ❑ No E:] THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANTS NAME 1./I ,,,//'''�� (PRINTED B SIGNATURE) Az k- CG AV Ie, tel /' � f C DATE) I¢ �� LOCAL AGENCY USE ONLY THEA STATE I.D.NUMBER IS COMPOSED OF THE FOUR NbMEEBELOW STATE 104 COUNTY# JURISDICTION# FAC2IL # TANK# I E PERMIT NUMBER PERMIT APPROVED BV/DATE =PERMIT DATE THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. FORME (1291) - FILE THIS FORM WITH THj f AL AGENCY IMPLEMENTING THE UNDERGROUND STORK TANK REGULATIONS , - ?-- Itg�