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'JyJJM PS — Jl ..,r STATE OF CALIFORNIA .. - ' n 3 STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 2 5 CHANGE OF INFORMATION O 7 PERMANENTLY CLOSED DOONSITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED -/ Ty a rpP 9 f��n !lL I. TANK DESCRIPTION COMPLETE ALL ITEMS-- SPECIFY IF UNKNUWN A. OWNERS TANK I.D.# O 1 S. MANUFACTURED BY: koo G./n�, C DATE INSTALLED(MO/DAY/YEAR) ✓H pWA D. TANK CAPACITY IN GALLONS: 1d CVv II. T AN�K GUN I tN I J IFA-116MAHNtV,VVmrtciuicm... .______...-. C. ❑ taUNL UL 3 DIESEL ❑ 6 AVIATION GAS A MOTOR VEHICLE FUEL ❑ 4 OIL G ' B. ED 4 GASAHOL ❑ 7 METHANOL F-12 PETROLEUM ❑ 80 EMPTY Q" 1 PRODUCT ❑ 10 PREMIUM UNLEADED ❑ 5 JETFUEL O 3 CHEMICALPRODUCT O 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. #: —NIPnnA,PTnrIPTI/1\I AMnc eMn Al TWAT 4PPI IFS IN ROX D ANDF _...___. .______...-. A U 1 SUCTION A U ❑ 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER O 95 UNKNOWN A. TYPE OF SYSTEM ❑ 2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTEDTANK) ❑ 99 OTHER A U ❑ 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/ FIBERGLASS REINFORCED PLASTIC B. TANK MATERIAL ❑ s CONCRETE ❑ 6 POLYVINYL CHLORIDE 7 ALUMINUM oI� ❑ B 1009: METHANOL COMPATIBLE W/FRP (PrimaryTank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL [o H5 UNKNOWN ❑ 99 OTHER INTERSTITIAL MONITORING ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING C. INTERIOR ❑ 5 GLASS LINING ❑ 6 UNLINED �5 UNKNOWN ❑ B9 OTHER LINING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL 7 VES _ NO— D. CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING 3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 9/ NONE UNKNOWN ❑ 99 OTHER E. SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED (YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED (YEAR) IV. PIPING INFORMATION CIRCLE A IFABOVEGROUNOOR U IF UNDERGROUND, BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A 5 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 7 STEEL W/ COATING A U A©95 UNKNOWN A U 4 FIBERGLASS PIPE 9 100% METHANOL COMPATIBLE W/FRP 99 OTHER D. LEAK DETECTION �' AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING ❑ J INTERSTITIAL MONITORING ❑ gg OTHER V. TANK LEAK DETECTION ❑ 1 VISUAL CHECK �2 INVENTORY RECONCILIATION O 3 VADOZE MONITORING ❑ 4 AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING ❑ 6 TANK TESTING ❑ 7 INTERSTITIAL MONITORING ❑ 91 NONE ❑ 95 UNKNOWN O 99 OTHER VI. TANK CLOSURE INFORMATION 1. ESTIMATED DATE LAST USED (MO/DAY/YR) 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 (PRINTED A SIGNATURE) LOCAL AGENCY USE ONLY THE STATE I.D. NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY# TANK# (SISAL Iy STATE I.D.# Yll = ploliltol-SU LE6 1 8 PERMITNUMBER PERMIT APPROVED BV/DATE PERMIT EXPIRATION DATE /�/ �Z FORM B (7-91) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION • FORM A, UNLESS A CURRENT FORM A HAS BEEN FILED. i R5