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STATE OF CALIFORNIA t uti C , STATE WATER RESOURCES CONTROL BOARD , UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B `' Ila, COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM, MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSE ITE ONE ITEM ❑ 2 kNTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ B TANK REMOVED/ DBA OR FACILITY NAME WHERE TANK IS INSTALLED: 2 10 tA/je mos,& ❑ 5 CONCRETE L TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A. OWNER'S TANK I. D. # B. MANUFACTURED BY: C. DATE INSTALLED (MOlDAYNEAR) v m D. TANK CAPACITY IN GALLONS: pod 11 TARIV PnKITCIUTC 117 , -4a A DVCn rMAPI CTC I7G6An A ❑ 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C. ❑ 1aREGULARUNLEADED L?IrDIESEL C 6 AVIATION GAS ❑ 4 GASAHOL �ETROLEUM 0 BO EMPTY 1 PRODUCT ❑ 1b(PIREMIUM ❑ 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. #: III T A AI V rinhlCTDI Ie-TIn KI ...nv —1.— nate V tat oIVCC A o AWMn Akin &I I TWAT APPI IGC INRr]5rn amn F IV, PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND, BOTH IF APPLICABLE A. SYSTEM TYPE ❑ 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN A. TYPE OF SYSTEM g�-2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTEDTANK) ❑ 99 OTHER SINGLE WALL 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/ FIBERGLASS REINFORCED PLASTIC B. TANK ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 6 1001/ METHANOL COMPATIBLE WIFRP MATERIAL (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER 6 CONCRETE A U ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING C. INTERIOR ❑ 5 GLASS LINING ❑ 6 UNLINED �9 NKNOWN ❑ 99 OTHER LINING ❑ 1 AUTOMATIC LINE LEAK DETECTOR 2 LINE TIGHTNESS TESTINGIIIJ�� ❑ MONITORING ❑ 99 OTHER LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO— `IIS 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC D. D. CORROSION PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE I' NOWN ❑ 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 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION AV 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 B 100% METHANOL COMPATIBLE WIFRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U &NKNOWN A U 99 OTHER D. LEAK DETECTION ❑ 1 AUTOMATIC LINE LEAK DETECTOR 2 LINE TIGHTNESS TESTINGIIIJ�� ❑ MONITORING ❑ 99 OTHER V. 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 (MOIDAYNA) 2. ESTIMATED QUANTITY OF 3. WAS TANK FILLED WITH YESNO SUBSTANCE REMAINING GALLONS INERT MATERIAL? ❑ 0 THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO TlIE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANTS NAME DATE (PRINTED S SIGNATURE) LOCAL AGENCY USE ONLY THE STATE I.D. NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY # JURISDICTION # FACILITY # TANK # A�fj� Zl STATE I.Q.#I I r Is o PERMIT NUMBER PERMIT APPROVED BYIDATE PERMIT EXPIRATION DATE FORM B (7-91) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION - FORM A, UNLESS A CURRENT FORM A HAS BEEN FILED.lit f ?� FDR0IX3413�5