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ee6ovR e c e STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION . FORM B o C�tIFOPNN COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ ERMANENTLY CLOSED ON SITE MARK ONLY 0 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE 8 TANK REMOVED v T ONE ITEM 1 DBA OR FACILITY NAME WHERE TANK IS INSTALLED: y 36 W Sc o I. TANK DESCRIPTION COMPLETE ALL ITEMS-- SPECIFY IF UNKNOWN B. MANUFACTURED BY: �[IC A. OWNERS TANK I.D.% � q u t/CQ ) acs D. TANK CAPACITY IN GALLONS: Z� p O Y�c C. DATE INSTALLED(M(YDAY'YEAR) p II.TANK NTENTS IF IS MARKED.COMPLETEITEMC. aREGULAm ❑ 3 DIESEL ❑ 6 AVIATIONGAS i MOTOR VEHICLE FUEL ❑ 4 OIL B. U. �UNLEADED ❑ 4 GASAHOLA 1 PRODUCT 7 METHANOL 2 PETROLEUM ❑ 80 EMPTY D ❑ 5 JET FUEL 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE 99 OTHER (DESCRIBE IN ITEM D. BELOW) D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED III. TANK CONSTTRRUCTION MARK ONE ITEM ONLY IN BOXES A.B.AND C,ANDALLTHATAPPLIES INBOXD 1,B6UBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN rB. TANK PE Of L^(d'/ ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER STEM 2 GLE WALL 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD WI FIBERGLASS REINFORCED PLASTIC 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM 8 100% METHANOL COMPATIBLE WIFRPTERIAL ❑mary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED ❑ 2 KYD LINING ❑ 3 EPDXY LINING 4 PHENOLIC LINING C.INTERIOR ❑ 5 GLASS LINING 8 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER LINING IS LINING MATERIAL COMPATIBLE WITH 100%NETHANOL 7 VES_ ❑ 1 POLYETHYLENE WRAP ❑ COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC D.CORROSION 95 UNKNOWN 99 OTHER PROTECTION F-15 CATHODIC PROTECTION 91 NONE ❑ IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U A U 2 PRESSURE A U 3 GRAVITY A U 95 UNKNOWN A U 99 OTHER A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH FIBERGLASS PIPE A U RE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A U 4 C. MATERIAL AND A U 5 ALUMINUM A U 6 CONCRETE A U7 STEELW/COATING A U 8 100% METHANOL COMPATIBLEWIFRP CORROSION PROTEION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER CT3 INTERSTRIAL 99 OTHER D. LEAK DETECTION ❑ 1 AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING ❑ MONITORING ❑ V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK 2 INVENTORY RECONCILIATION ❑ 3 VAPOR MONITORING❑ 4 AUTOMA71CTANK GAUGING ❑ 5 GROUND WATER MONITORING 6 TANK TESTING ❑ 7 INTERSTITIAL MONITORING ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION S.WAS TANK FILLED WITH YES ❑ NO 2.ESTIMATED REMAINING OF 1.ESTIMATED DATE LAST USED(MO1OAYIVR) SUBSTANCE REMAINING GALLONS INERT MATERIAL? /ij C0 �93 THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANTS NAME (PRINTED d SIGNATURE) LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW Ike COUNTY# JURISDICTION# FACILITY# TANK# � 1,41 STATE I.D.# F57 = � �''�J PERMIT APPROVED BY)DATE PERMIT EXPIRATION gQTE 3/y3 PERMIT NUMBER l.C) FORM B (9.90) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. FOR00346R4