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• °`�.. 0 STATE OF CALIPoRNIA ,� '"� STATE WATER RESOURCES CONTROL BOARD w m a UNDERGROUND STORAGE TANK PERMIT APPLICATION • FORM B �>o , Cl m> . COMPLETE A SEPARATE FORM FOR TANK SYSTEM. �� MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT EVS CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOS-D ON SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED 013 DBA OR FACILITY NAME WHERE TANK IS INSTALLED: /fiv— oil eo - 1. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN /y� A. OWNER'S TANK I.D.# /ufq 5 OQZ B. MANUFACTURED BY: U4I-e-Y //7 C. DATE INSTALLED(MOIDAY/YEAR) I q Lf D. TANK CAPACITY IN GALLONS: O ILTANKCONTENTS IFA-11S MARKED,COMPLETEITEM C. a REGULAR A. ❑ 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C. ❑ I UNLEADED e 4 GASAHOL 3 DIESEL ❑ 6 AVIATIONGAS ❑ 2 PETROLEUM ❑ EMPTY 1 PRODUCT ❑ 1bUNLEADED JETFUEL E] 7 METHANOL ❑ 3 CHEMICAL PRODUCT UNKNOWN ❑ 2 WASTE ❑ 2 LEADED OTHER (DESCRIBE IN ITEM D. BELOW!) D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED om C.A.S.is III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A B,AND C,AND ALLTHAT APPLIES IN BOX A. TYPE OF ❑ DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER E�r1 BARE STEEL ❑ 2 STAINLESS STEEL E:] 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B. TANK MATERIAL ❑ 5 CONCRETE ❑ e POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED ❑ 2ALKYD LINING E] 3 EPDXY LINING ❑ 4 PHENOLIC LINING C.INTERIOR ❑ 6 GLASS LINING ,LT'11J/ UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER LINING IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL 7 YES— NO— D.CORROSION ❑ 1 POLYETHYLENE WRAP ❑ ATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION 91 NONE ❑95 UNKNOWN ❑ 99 OTHER IV.PIPING INFORMATION CIRCLE A IFABOVEGROUNDOR U IF UNDERGROUND,B PP (CABLE A. SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 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 PIPE CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEELWICOATING A U 8 100% METHANOL COMPATISLEW/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U05 UNKNOWN A U 99 OTH D. LEAK DETECTION ❑ 1 AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING ❑ 3ILMgNRORINGL OTHER �� IC� V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VAPOR MONITORING❑ 4 TOMATIC 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(MOIDAY/YR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES NO SUB STA NCE REMAINING GALLONS INERTMATERIAL7 ❑ ❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANTS NAME DATE (PRINTED 6 SIGNANRE) LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY# TANK# STATE LD.#PlnA03o W79 I 1 11 018 (DI21II PERMIT NUMBER PERM IT APPROVED BY/DATE PERMIT EXPIRATION DATE FORM 8 (9.90) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. FONO#N6R1�