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.J STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B c„ COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 ERMANENTLY CLOSED ONSITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE I �I ",TANK REMOVED O DBA OR FACILITY NAME WHERE TANK IS INSTALLED: �p 7 E A. OWNER'S TANK I. D. s 3 B. MANUFACTURED BY: C. DATE INSTALLED(MO/DAYNEAR) ' -/SO 0. TANK CAPACITY IN GALLONS: 11 600 II TAAIVe%OIARCARC rTmI FTFITSun A _ 1 ❑ 2 MOTOR VEHICLE FUEL PETROLEUM ❑ 4 OILB. ❑ 60 EMPTY 1 PRODUCT C. ❑ la REGUL R ❑ 1_ IR EAIDUEMO O 4 DIESEL ❑ 6 AVIATIONGAS ❑ 5 JET FUEL F-]7 METHANOL ❑ 3 CHEMICAL PRODUCT❑ 95 UNKNOWN ❑ 2 WASTEEADED ❑ 2 STAINLESS STEEL ❑ 98 OTHER (DESCRIBE IN ITEM 0. BELOW) D. IF (A.1) IS NOT MARKED. ENTER NAME OF SUBSTANCE STORED ❑ 5 CONCRETE C. A. S. s: III TAKIV ^^KIQT0"f%TIflN ...—k- v A1nnr AMn ell TWATAPPI IFS IN FnVnGNnF A. TYPE OF ❑ 11 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM LLQ 2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER B. BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/ FIBERGLASS REINFORCED PLASTIC B. TANK MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 6 100% METHANOL COMPATIBLE WIFRP (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER 4 FIBERGLASS PIPE B 100% METHANOL COMPATIBLE W/FRP 99 OTHER ❑ i RUBBER LINEDn 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING C. INTERIOR ❑ 5 GLASS LINING ^; UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER LINING LS LINING MATERIAL COMPATIBLE WITH 10016 METHANOL? YES_ NO— D. CORROSION ❑ I POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 V L WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE UNKNOWN ❑ 99 OTHER E. SPILL AND OVERFILL SPILLOONTAWMENT INSTALLED (YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED (YEAR) IV PIPIKIr INFORMATION CIRBIF A IF AROVF GROIINn OR U IF UNDERGROUND. BOTH IF APPLICABLE A. SYSTEM TYPE U sucTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTK)N U 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 GALVANQED STEEL A U A U A U 2 STAINLESS STEEL A U 6 CONCRETE A U /0 CATHODIC PROTECTION 3 POLYVINYL CHLORIDE (PVC) A U 7 STEEL W/ COATING A U AIM95 UNKNOWN A U 4 FIBERGLASS PIPE B 100% METHANOL COMPATIBLE W/FRP 99 OTHER D. LEAK DETECTION ❑ 1 AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING ❑ 3 MONIAL RORING ❑ 99 OTHER !. 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. ESTIMATE / T=3E 4 V/ R) 2 SUBIS ANCE REMAI NGF GALLONS S WASNERT MATERIAL(? YES ❑ NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CO F APPLICANTS NAME DATE (PRINTED 6 SIGNATURE( ! // LOCAL AGENCY USE ONLY THE STATE I.D. NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW " T'A n e Yd 7 COUNTY R JURISDICTION u FACILITY x TANK x STATE I.D.# FxW 7T--1 FT T7 TQI2 inl II I 1 11 1".?l PERMIT NUMBER FORM B (7-91) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION • FORM A, UNLESS A CURRENT FORMA HAS B_ EWILED"(�jj