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'SOugCe 4 STATE OF CALIFORNIA STATE WATER:RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM B a COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ❑ 1 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 B TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A. OWNER'S TANK I.D.a O � I B. MANUFACTURED BY: C, DATE INSTALLED(MO/DAY/YEAR) ' % 7�L- O. TANK CAPACITY IN GALLONS: II,TANK CONTENTS iFA-1 IS MARKED.COMPLETE ITEM C. REGULAR A. 5✓ 1 MOTOR VEHICLE FUEL 4 OIL B. C- 1eUNLEADED 3 DIESEL g AVIATION GAS ❑ 2 PETROLEUM ❑ 80 EMPTY E�L1 PRODUCT ❑ 1b PREMIUM 4 GASAHOL 7 METHANOL UNLEADED El 5 JET FUEL ❑ 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 STOREDfj C.A.S.a III. TANK CONSTRUCTION MARK ONE ITEM ONLY 1N BOXES A.B.AND C,AND ALL THAT APPLIES IN BOX D AND E�jk- fS�� L�• /IC, Z.3. S'4 A. TYPE OF ❑ 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER 95 UNKNOWN SYSTEM N-�12 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) 99 OTHER B. TANK �1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS 4 STEEL CLAD W FIBERGLASS REINFORCEO PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM B 100% METHANOL COMPATIBLE WIFRP (PHmaryTank) 9 BRONZE 10 GALVANIZED STEEL 95 UNKNOWN 99 OTHER 1 RUBBER LINED 2 ALKYD LINING ❑ 3 EPDXY LINING 4 PHENOLIC LINING C,INTERIOR 5 GLASS LINING S UNLINED 95 UNKNOWN 99 OTHER eDLINING IS LINING MATERIAL COMPATIBLE WI 100% METHANOL? YES__._ Ne— D. .CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING 3 VINYL WRAP Q 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE 95 UNKNOWN E::] 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 IFUNIjERGROUND,BOTH IFAPPLICABLE F A. SYSTEM TYPE A U 1 SUCTION Aip" PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION k-lr7;? 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 9 CONCRETE A U 7 STEEL WICOATING A U 9 100% METHANOL COMPATIBLE WIFRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION oCrb5 UNKNOWN' A U 99 OTHER D. LEAK DETECTION ❑ 1':AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING ❑ 3 INT Ir10N{TO INGIlIl ❑ 99 OTHER V.TANK LEAK DETECTION ❑ i VISUAL CHECK 2 INVENTORY RECONCILIATION ❑ 3 VADOZE MONITORING 4 AUTOMATIC TANK GAUGING 5 GROUNDWATER MONITORING 6 TANK TESTING INTERSTITIALMONITORWG91 NONE 95 UNKNOWN 99 OTHER VI.TANK CLOSURE INFORMATION 1.ESTIMATED DATE LAST USED(MO/DAYNR) 2.ESTIMATED OUANTITY 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, 1S TRUE AND CORRECT APPLICANTS NAME DAA (PRINTED 6 SIGNATURE) LOCAL AGENCY USE ONLY THE STATE 1,0,NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW' COUNTY# JURISDICTION# FACILITY# TANK# STATE-I.D.# Z o PERMITNUMBER PERMIT APPROVED BYIDATE PERMIT EXPIRATION DATE i THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED, L f FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS FORM 8 (12-91) FOR00348•R6 {