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I.R�• yrt1. P i1 t ITATE OF CALIFORNIA r , STATE WATER RESOURCES CONTROL BOARD W" o UNDERGROUND STORAGE TANK PERMIT APPLICATION -FORM B w ;, fit crow N`r COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ONSITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 8 TEMPORARY TANK CLOSURE 0 8 TANK REMOVED j DBA OR FACILITY NAME WHERE TANK IS INSTALLED: CZ- rte' 1 L TANK DESCRIPTION COMPLETE ALL ITEMS-- SPECIFY IF UNKNOWN !F C/'� A. OWNER'S TANK L D.4 B-13 . MANUFACTURED BY: � �L...r� J C. DATE INSTALLED(MO1DAYNEAR) / D. TANK CAPACITY IN GALLONS: II.TANKCONTENTS IFA-1 IS MARKED,COMPLETE ITEM C. DIESEL REGULAR ,M3 A ❑ 1 MOTOR VEHICLE FUEL a 4 OIL B. C. ❑ 1aUNLEAOED ❑ 4 GASAHOL ❑ 6 AVIATION GAS ❑ 7 METHANOL <2 PETROLEUM ❑ 80 EMPTY 1 PRODUCT ❑ 1b(PREAIDED ❑ 5 JET FUEL 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED ❑ 99 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 MARK ONE ITEM ONLY IN BOXES A.B,AND C,AND ALLTHAT APPLIES IN BOX D AND E A, TYPE OF 1 DOUBLE WALL 713 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM ❑ 2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) 99 OTHER ❑ 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ® 4 STEEL CLAD W!FIBERGLASS REINFORCED PLASTIC B. TANK5 CONCRETE F-1 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM L] a 100% METHANOL COMPATIBLE WIFRP MATERIAL (PrimaryTank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL 95 UNKNOWN ❑ 99 OTHER 0 I RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING C.INTERIOR ❑ 5 GLASS LINING ❑ S UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER LINING IS LINING MATERIAL COMPATIBLE WITH 100/METHANOL? YES_ ND— ❑ 1 POLYETHYLENE WRAP F-] 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC D.CORROSION PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE 95 UNKNOWN 99 OTHER E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND.BOTH IF APPLICABLE A. SYSTEM TYPE A U f1 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 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 PIPE CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL WI COATING A U B 100% METHANOL COMPATIBLEWIFRP 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 MON QRING ❑ OTHER SGL�>a�' rna��I I� V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VADOZE MONITORING ❑ 4 AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING ❑ 6 TANK TESTING 1 INTERSTITIAL MONITORING ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION 1.ESTIMATED A E LA 'SED(MO/DAYIYR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES ❑ NO O SUBSTANCE REMAINING GALLONS I INERT MATERIAL? THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO TPE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT DATE APPLICANTS NAME (PRINTED&SIGNATURE) LOCAL AGENCY USE ONLY THE STATE I,D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW /3ElC I COUNTY# JURISDICTION# FACILITY# TANK# STATE {.D.# �� I PERMIT NUMBER ERM IT APPROVED BY/DATE PERMIT EXPIRATION DATE THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE J�JNDEJRGROUND STORAGE TANK REGULATIONS FOR94348-F6 FORM 9 (12-91) (",/ / yLr / - •} J- _ '" j i,`'T7