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Y SPURGES STATE OF CALIFORNIA PG c°s STATE WATER RESOURCES CONTROL BOARD 3_ ,d UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM B COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSE ONE ITEM X 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT /�❑ 66 TEMPORARY TANK CLOSURE E] 8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: 1870 E. /7 ZG I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A. OWNER'S TANK I.D.A w pp B. MANUFACTURED BY: C. DATE INSTALLED(MO/DAYNEAR) A-��tiv- . D. TANK CAPACITY IN GALLONS: 000 ILTANKCONTENTS IFA-11SMARKED,COMPLETE ITEM C. A. ❑ 1 MOTOR VEHICLE FUEL 4 OIL 8. C ❑ 1aUNLEADED 3 DIESEL 6 AVIATIONGAS REGULAR ❑ 4 GASAHOL PETROLEUM ❑ 80 EMPTY ❑ 1 PRODUCT ❑ 1bUNLEAIDED ❑ 5 JET FUEL 7 METHANOL ❑ 3 CHEMICAL PRODUCT 95 UNKNOWN 2 WASTE ❑ 2 LEADED F-] 99 OTHER (DESCRIBE IN ITEM D. BELOW) D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED Lo as ff- &u C.A.S.n: 0 III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A,B,AND C,AND ALL THAT APPLIES IN BOX D AND E A. TYPE OF ❑ 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM2 SINGLE WALL F-14 SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER B. TANK 15 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 1009% METHANOL COMPATIBLE W/FRP (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER F71 RUBBER LINED ❑ 2 ALKYD LINING F-] 3 EPDXY LINING 4 PHENOLIC LINING C.INTERIOR ❑ 5 GLASS LINING 5zr 6 UNLINED ❑ 95 UNKNOWN ❑ 99 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 F--] 5 CATHODIC PROTECTION [-] 91 NONE 1✓�Cf 95 UNKNOWN ❑ 99 OTHER E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR) ��lll OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) _ IV.PIPING INFORMATION CIRCLE A IFABOVEGROUNDOR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A40 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND U 1 BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A U 4 FIBERGLASS PIPE CORROSION A16 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL W/COATING A U 8 1009/6 METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION 1 AUTOMATIC LINE LEAK DETECTOR 2 LINE TIGHTNESS TESTING ❑ 3 INTERSTITIAL MONITORING ❑ 99 OTHER VTANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VADOZE MONITORING ❑ 4 AUTOMATIC TANK GAUGING 5 GROUND TER G 6 TANK TESTING F-17 INTERSTITIAL MONITORING ❑ 91 NONE ❑ 95 ONKN6WN 99 OTHE / NK. ¢. Vi.TANK CLOSURE INFORMATION _ — e 1.ESTIMATED D/\TE LAST USED(MO/DAYNR) 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 APPLICANTS NAME DATE (PRINTED 8 SIGNATURE) LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOWpk3'pc�3 i j COUNTY# JURISDICTION# FACILITY# TANK# STATE I.DA hL7_� a11 11 14 111 Ill JL+ PERMIT NUMBER PERMIT P OVED Y/DA � PERMIT EXPIRATIO,ND ATE FORM B (7-91) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. / FOR00348-RS II _