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esu ^ e c STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD + UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B W tl� "° ., o COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION CI, 7 PERMANENTLY CLOSED ON SITE ONE REM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ B TANK REMOVED 0 4 DBA OR FACILITY NAME WHERE TANK IS INSTALLED:I& _,�: l/SCyv I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A. OWNER'S TANK 1.D.i �2- S. MANUFACTURED BY: c�Nlc C. DATE INSTALLED(MO/OAYNEAR) al.tk- O. TANK CAPACITY IN GALLONS: ILTANKCONTENTS IFA-1 IS MARKED.COMPLETE ITEM C. A ❑ MOTOR VEHICLE FUEL ❑ 4 OIL 8. C. ❑ I&REGULAR ED 8 4 DIESEL ❑ 9 AVIATION GAS �2 PETROLEUM ❑ 90 EMPTY �1 PRODl1CT ❑ 1-6NLEAD D nF�-� 5 JIFTFUEL ❑ ] METHANOL ❑ 3 CHEMICALPRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED u 99 OTHER (DESCRIBE IN ITEM D. BELOW) D. IF(A1)IS NOT MARKED. ENTER NAME OF SUBSTANCE STORED � C.A S.i s III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A 8,AND C.AND ALL THAT 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 ❑ R. TANK 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD Wl FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 8 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 6 100% METHANOL COMPATIBLE W/FRP (PrimaryTalk) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL �95 UNKNOWN ❑ N OTHER ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING C.INTERIOR ❑ 5 GLASS LINING ❑ 6 UNLINED Z96 UNKNOWN ❑ N OTHER LINING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO— D.CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE ilm/ UNKNOWN ❑ N OTHER IV.PIPING INFORMATION CIRCLE A IFABOVEGROUNDOR U IFUNDERGROUND.BOTHIFAPPLICABLE A. SYSTEM TYPE A U I SUCTION A U 2 PRESSURE A U 3 GRAVITY A U N OTHER 01"k8. CONSTRUCTION A U 1 SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH 95 UNKNOWN A U N OTHER C. MATERIAL AND A U I RARE 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 8 100% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODICPROTECTION Aldo" UN194OWN A U N OTHER D. LEAK DETECTION ❑ 1 AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING O 7 ERSTI IAL ❑ 99 OTHER MONITORING V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VAPOR MONITORING�4 AUTOMATIC TANK GAUGING ❑ 5 GROUNO WATER MONITORING ❑ 9 TANK TESTING ❑ 7 INTERSTITIAL MONITORING ❑ 91 NONE 95 UNKNOWN ❑ N OTHER VI.TANK CLOSURE INFORMATION 1.ESTIMATED DATE LAST USED(MO/DAY/YR) 2.ESTIMATED QUANTITY OF �J 3.WAS TANK FILLED WITH YES NO 1 /171/( 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 (VPoNTEO!SIGNATYRE) LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# TANK# STATE LDAPERMITNUMBER PERMIT APPROVED 8Y/OATE PERMIT EXPIRATION DATE p/ FORM B (9 90 THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. FOR0031BRI i