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• �es�..,,. �o STATE OF CALIFORNIA '� a STATE WATER RESOURCES CONTROL BOARD s` 4 UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B �� e COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. ��,.°"P�' MARK ONLY ❑ i NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ON SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ro/S TANK REMOVED O DBA OR FACILITY NAME WHERE TANK IS INSTALLED: 5+ f�, M a re,— /6vj, I. TANK DESCRIPTION COMPLETE ALL ITEMS-- SPECIFY IF UNKNOWN A. OWNER'S TANK I.D. D I B. MANUFACTURED BY: C. DATE INSTALLED(MOADAWVEAR) �(�yV(/,L D. TANK CAPACITY IN GALLONS: 119 000 II.TANK CONTENTS IFA-1 IS MARKED,COMPLETE ITEM C. A 1 MIOR VEHICLE FUEL ❑ 4 OIL B. C. ❑ 1eREGULAR NLEA ED 3 DIESEL ❑ 6 AVIATIONGAS L c PETROLEUM ❑ SO EMPTY i PRODUCT ❑ tb PREMIUM 4 GASAHOL ❑ 7 METHANOL UNLEADED ❑ 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 C.A.S. III. TANK CONSTRUCTION MARK OLNEITEM ONLY IN BOXESA.B.AND C,AND ALLTHAT APPLIES IN 13OXD A. TYPE OF ❑ 1 DOUBLE WALLVW�ITH1 GLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM ❑ 2 SINGLE WALLONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER ❑ 1 BARE STEELINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEELCLAD W/FIBERGLASS REINFORCED PLASTIC B. TANK MATERIAL ❑ 5 CONCRETEYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ S 100% METHANOL COMPATIBLE W/FRP (Primary Tank) ❑ 9 BRONZELVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINEDD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING C.INTERIOR ❑ 5 GLASS LININGINED ❑ 95 UNKNOWN ❑ 99 OTHER LINING IS LINING MATERIAL COMMETHANOL? VES_ NO— D.CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2CO TING ❑ 3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION E:] 91 NO ❑ 95 UNKNOWN E] 99 OTHER IV.PIPING INFORMATION CIRCLEAIFABOVEGROUNDOR IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION A U 2 PRIES RE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL A U 2 DOUBLE ALL 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 TEEL A U 3 POLYVINYL CHLORIDE(PVC)A U 4 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 6CONCRETE A U 7 STEELW/COATING A U 6 100% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PR TECTION A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION ❑ 1 AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE HTNESS TESTING ❑ 3 MONITORING ERSTITIAL E:] 99 OTHER V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VAPOR MONO❑ 4 AUTOMATIC TANK GAUGING [—] 5 GROUND WATER MONITORING E] 6 TANK TESTING ❑ 7 INTERSTITIAL MONITORING [7] ORI 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION 1.E IMATED DATE LAST SED(MO/DAV/VR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES NO SUBSTANCE REMAINING Q O GALLONS INERTMATERIAL7 ❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANTS NAME DATE (PRINTED b SIGNATURE( LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY# TANK# STATE LDA L3T91 PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE FORM B (9-90) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. FORGO B-N I Ilk