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OOR STATE OF CALIFOFNA STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION-FORM B Ab a 0 COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 6 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ONSrTE ONE ITEM ❑ 2 INTERIM PERMIT 04 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED 0 DBA OR FACILITY NAME WHERE TANK IS INSTALLED: klS e4 e 1422 a� 3 c/t f-olk,ipl / ,r I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A. OWNERS TANK 1.D.S T B. MANUFACTURED BY: C. DATE INSTALLED(MOIDAYtf EAR) D. TANK CAPACITY IN GALLONS: 11.TANK C2EENTS IFA-1 IS MARKED,COMPLETE ITEM C. A. E�Tl MOTOR VEHICLE FUEL 0 4 OIL B. EBp C. EET'la REGULAR 3 DIESEL E] 6 AVIATION GAS --j 2 PETROLEUM 7 80 EMPTY 1 1 UNLEADED 4 GASAHOL F F PRODUCT b PREMIUM F7 7 METHANOL UNLEADED ❑ 5 JET FUEL E:j 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN E::] 2 WASTE E:] 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: 111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.13,AND C.AND ALL THAT APPLIES IN BOX D A. TYPE OF F-� I L-WALL f73 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN 'DOUSI SYSTEM @--I 2-SINGLE Ej 4 SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER -- z B. TANK F—ii;17 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS E:] 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE F-1 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLEW/FRP (Primary Tank) E:] 9 BRONZE ❑ 10 GALVANIZED STEEL 0 96 UNKNOWN ❑ 99 OTHER C.INTERIOR F-� I RUBBER LINED ❑ 2 ALKYD LINING F-13 EPDXY LINING ❑ 4 PHENOLIC LINING F-� LINING 5 GLASS LINING UNLINED ® 95 UNKNOWN 99 OTHER IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? YES— NO._ D.CORROSION ❑ I POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION D 5 CATHODIC PROTECTION E] 91 NONE [AA&-WKNOWN ❑ 99 OTHER IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U I SUCTION A(p PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION l SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND A S)l 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 6 CONCRETE A U 7 STEEL WICOATING A U 8 100% 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 0 1 AUTOMATIC LINE LEAK DETECTOR E] 2 LINE TIGHTNESS TESTING ❑ 3 INTFASTITAL [:]99 OTHER MONITORING V.TANK LEAK DETECTION ❑ 1,41SUAL CHECK [oo�2 INVENTORY RECONCILIATION E] 3 VAPOR MONITORING❑ 4 AUTOMATIC TANK GAUGING❑ 6 GROUNDWATER MONITORING Eff6 TANK TESTING ❑ 7 INTERSTITIAL MONITORING 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER V1.TANK CLOSURE INFORMATION 1.ESTIMATED DATE LAST USEDR)(MO/DAY/Y2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH &-4L11 - * EE'SUBSTANCE REMAINING GALLONS I INERT MATERIAL? YES F-1 NO F7 THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANT'S NAME DATE (PRINTED&SIGNATURE) LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY# TANK# STATE I.D.# FT-F I I I TI I I PERMIT NUMBER PERMIT APPROVED BY/DATE — PERMIT EXPIRATION DATE FORMS (9-90) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. FORMS�R4