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3 A. OWNERS TANK 1. 0. S. MANUFACTURED BY: C DATE INSTALLED(MO/DAY/YEAR) Vh ,� D. TANK CAPACITY IN GALLONS: ld Q© A 1 MOTOR VEHICLE FUEL ❑ 4 OIL STATE OF CALIFORNIA 10 STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B 3 m u o 3 DIESEL ❑ 6 AVIATION GAS 4 GASAHOL COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. rVJ�/ 1 PRODUCT MARK ONLY ONE ITEM ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ON SITE ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: 13 Z i-) (� ❑ 2 WASTE 1 TAAIVnCQ/`0IDTIi1M SPI PS Al I ITF.IC_ 9PFCIFV IF UNKNOWN 99 OTHER (DESCRIBE IN ITEM D. BELOW) A. OWNERS TANK 1. 0. S. MANUFACTURED BY: C DATE INSTALLED(MO/DAY/YEAR) Vh ,� D. TANK CAPACITY IN GALLONS: ld Q© A 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. / kR GULA C. 1aUNELEADED 3 DIESEL ❑ 6 AVIATION GAS 4 GASAHOL ❑ 2 PETROLEUM ❑ 80 EMPTY rVJ�/ 1 PRODUCT ❑ 1:R UNLEADED ❑ 5 JET FUEL ❑ 7 METHANOL ❑ 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. #: un Ol�n�AA ATI^ AI o .1 Iola _vnl lun PnTU IP APPI In4RI F ,.., A. ,. ..... .... ........... SYSTEM TYPE _.. A U _...___ .. .. . 1 SUCTION A PPRESSURE ❑ 1 WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN A. TYPE OF SYSTEM2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTEDTANK) ❑ 99 OTHER A U ❑ I BARE STEEL ❑ 2 STAINLESS STEEL F73 FIBERGLASS E]4 STEELCLAD W/FIBERGLASS REINFORCED PLASTIC B. TANK ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUM IN ❑ 8 100% METHANOL COMPATIBLE W/FRP MATERIAL (PfimeryTank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL 5 UNKNOWN ❑ 99 OTHER 5 ALUMINUM ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY INING ❑ 4 PHENOLIC LINING C. INTERIOR ❑ 5 GLASS LINING ❑ 6 UNLINED5 UNKNOWN ❑ 99 OTHER LINING 10 CATHODIC PROTECTION U 95 UNKNOWN A U 99 OTHER D. IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES _ NO MONRORING ❑ 99 OTHER ❑ I POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINY AP ❑ 4 FIBERGLASS REINFORCED PLASTIC D. CORROSION PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE UNKNOWN ❑ 99 OTHER E. SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED (YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED (YEAR) un Ol�n�AA ATI^ AI o .1 Iola _vnl lun PnTU IP APPI In4RI F ,.., A. ,. ..... .... ........... SYSTEM TYPE _.. A U _...___ .. .. . 1 SUCTION A PPRESSURE - A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A 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 STEELW/COATING A U 9 100% METHANOL COMPATIBLEW/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION AUTOMATIC LINE LEAK DETECTOR 2 LINE TIGHTNESS TESTING ❑ 3 MONRORING ❑ 99 OTHER I, TANK LEAK DETECTION ❑ 1 VISUAL CHECK 2 INVENTORY RECONCILIATION ❑ 3 VADOZE 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. ESTIMATED DATE LAST USED (MO/DAYNR) 2. ESTIMATED QUANTITY OF 3. WAS TANK FILLED WITH YES NO SUBSTANCE REMAINING GALLONS INERT MATERIAL? ❑ ❑ -rule cnoAA WA aFFN roMPI FTFD UNDFR PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANTS NAME DATE (PRIMED 6 SIGNATURE) nrAl ArPMrV I ICF nNl V TNP STATE I n. NUMRFP IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY # JURISDICTION # FACILITY # TANK # STATE LD.# T/ PERMIT NUMBER PERMITAPPROVED BY/DATE �r �� PERMIT EXPIRATION DATE 1nI THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION • FORM A, UNLESS A CURRENT FORM A HAS BEEN FILE .L , ,'` FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULAI IUNS /lv- `` k3 F0014