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°6 w.u. °o STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD s` �O UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B w�"� y; COMPLETE ASEPARATE FORM FOR EACH TANK SYSTEM. ��iF°"�� MARK ONLY F-] 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ PERMANENTLY CLOSED ONSITE ONE ITEM ❑ 2 INTERIM PERMIT O 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE a TANK REMOVED 71 DBA OR FACILITY NAME WHERE TANK IS INSTALLED: D UA nAlrr I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A. OWNER'S TANK I.D.# # B. MANUFACTURED BY: �zlwL C. DATE INSTALLED(MO/DAYNEAR) L(�y) D. TANK CAPACITY IN GALLONS: 00-p ILTANKCONTENTS IFA-11S MARKED.COMPLETE ITEM C. n`�� A ❑ 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C. ❑ UNLEADREGED u 3 DIESEL ❑ 6 AVIATION GAS �I u 4 GASAHOL ❑ 2 PETROLEUM By EMPTY ❑ 16UN UNLEADED ❑ 5 JETFUEL ❑ 7 METHANOL ❑ 3 CHEMICALPRODUCT 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 a llzayl&4' C.A.S.F: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.B.AND C,AND ALLTHAT APPLIES IN BOX 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 F-11 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEELCLAD W/FIBERGLASS REINFORCED PLASTIC B. TANK MATERIAL. ❑ 5 CONCRETE ❑ 8 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ B 100% METHANOL COMPATIBLE W/FRP (PrimaryTank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING C.INTERIOR ❑ 5 GLASS LINING ❑ 6 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER LINING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? VES_ 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 IV.PIPING INFORMATION CIRCLE A IFABOVEGROUNDOR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER S. 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 W!COATING A U 9 100% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U /0 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION ❑ 1 AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINETIGHTNESSTESTING ❑ 3INTERSTITIAL ORING ❑ 99 OTHER V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VAPOR 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.ESTIMATFp.P E A TUS (MO/DAV/YR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH LU.! SUBSTANCE REMAINING GALLONS INERT MATERIAL 7 YES NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANTS NAME OATS (PRINTED&SIGNATURE) LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# ��FACILITY# TANK# STATE I.D.# = I I 1 / 1 2-Igiv I I 1 1 111)1:6 mo PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE FORMS (9.90) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. FOROMB-R4