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n ` � p,.,4 J9 p C, STATE OF CALIFORNIA S �fl �^ STATE WATER RESOURCES CONTROL BOARD 3 e. UNDERGROUND STORAGE TANK PERMIT APPLICATION . FORM B ew �a` o CRIIRORNIp COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ^ ONE ITEM ❑ 2 INTERIM PERMIT F-14 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ B TANK REMOVED l._� DBA OR FACILITY NAME WHERE TANK IS INSTALLED: �'L 3 Q 4m%e-- I. TANK DESCRIPTION COMPLETE ALL ITEMS -- SPECIFY IF UNKNOWN A. OWNER'S TANK I.D.# / B. MANUFACTURED BY: vH al— C. C. DATE INSTALLED(MOIDAYNEAR)y D. TANK CAPACITY IN GALLONS: IzG JI TANKCON S IFA I ISMARKED COMPLETEITEMC A i MOTOR VEHICLE FUEL ❑ 4 OIL B. REGULAR C. ❑ taUNLEADED � 4 DIESEL❑ GASAHOL 5 AVIATION GAS 7 METHANOL ❑ 2 PETROLEUM ❑ BO EMPTY 1 PRODUCT ❑ 1bUNLEAOED ❑ 5 JET FUEL ❑ ❑ 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 ❑ S 100% METHANOL COMPATIBLE W/FRP MATERIAL (PrimaryTank) C. A. S. # : La—NNKNOWN welt/ ^^kI07011P7IfU1 In AIIT.ATAGGII[SRJRnYn ANnP VV"VOy ,_.._.._... _.._. 1 SUCTION A PRESSURE A U ALL 1 WALL LE ❑ 3 SINGLE WALL WITH EXTERIOR LINER 3 E] 95 UNKNOWN A. TYPE OF A. SYSTEM 2 SINGLE ❑ 4 SECONDARY CONTAINMENT (VAULTEDTANK) ❑ 99 OTHER 2 DOUBLE WALL A U ❑ 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEELCLAD W/FIBERGLASS REINFORCED PLASTIC B. TANK F—]5 CONCRETE ❑ 6 POLYVINYL CHLORIDE 7 ALUMINUM ❑ S 100% METHANOL COMPATIBLE W/FRP MATERIAL (PrimaryTank) ❑ 9 BRONZE 10 GALVANIZED STEEL La—NNKNOWN 99 OTHER ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING C. INTERIOR ❑ 5 GLASS LINING ❑ 6 UNLINED UNKNOWN 99 OTHER LINING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL 7 YES— NO— ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC D. CORROSION PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE NKNOWN ❑ 99 OTHER E. SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED (YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED (YEAR) nlnuln Iuc^MRMATlnal ne 11 iv u,nn[o - iAin onTu l[eool V:ARI F A. SYSTEM TYPE A U 1 SUCTION A PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND CORROSION PROTECTION A U A U A U 1 BARE STEEL 5 ALUMINUM 9 GALVANIZED STEEL A U A U A U 2 STAINLESS STEEL A U 6 CONCRETE A U 10 CATHODIC PROTECTION 3 POLYVINYL CHLORIDE (PVC) A U 4 FIBERGLASS PIPE 7 STEEL W/COATING A U B 100% METHANOL COMPATIBLE W/FRP UNKNOWN A U 99 OTHER D. LEAK DETECTION TOMATIC LINE LEAK DETECTOR LINE TIGHTNESS TESTING ❑ 0 MONOOflING ❑ 99 OTHER U TAKIV I PAI( IIFTFCT10KI ❑,1, VISUAL CHECK 2 INVENTORY RECONCILIATION ❑ 3 VADOZE MONITORING ❑ 4 AUTOMATIC TANK GAUGING ❑ 5 GROUNDWATER MONITORING ❑ 6 TANK TESTING O 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? ❑ ❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANTS NAME DATE (PRINTED 8 SIGNATURE) nrAl Ar:FMCV IISF ONI V THF RTATF I.n NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY # JURISDICTION # FACILITY # TANK # STATE I.D.# PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION • FORM A, UNLESS A CURRENT FORM A HAS BEE FILED. FORM B (12-91) FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS 1 9- 2-27-7"\ X