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• STATE OF CALIFORNIA °o STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B W "` COM512TE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT 3 RENEWAL PERMITS CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ONSITE ONE ITEM 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT /�❑-' 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: 1. TANK DESCRIPTION COMPLETE ALL ITEMS — SPECIFY IF UNKNOWN ls�f&4 A. OWNER'S TANK I. 0. s B. MANUFACTURED BY: C. GATE INSTALLED (MO/DAY/YEAR) ";V/,/I f D 0. TANK CAPACITY IN GALLONS: 11. TANK NTENTS IFA -1 IS MARKED. COMPLETE ITEM C. A. FVJ 1 MOTOR VEHICLE FUEL ❑ 4 OILB. / C. 7118UREGULAR NLEADED 3 DIESEL 1:16 AVIATION GAS ❑ 2 PETROLEUM ❑ 80 EMPTY vZ/t PRODUCT I PREMIUM 4 GASAHOL UNLEADED 5 JETFUEL ❑ 7 METHANOL (❑ 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 STORED C. A. S. S: 111. TANK CONSTRWTION MARK ONE ITEM ONLY IN BOXES A. S. AND C. AND ALL THAT APPLIES IN BOX 0 AND E A. TYPE OF i DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER 95 UNKNOWN SYSTEM ❑ 2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) 99 , -OTHER B. TANK ❑ 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS 4 STEEL CLAD W/ FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER ❑ t RUBBER LINED ❑ 2 ALKYD LINING ❑ PDXY LINING 4 PHENOLIC LINING C. INTERIOR ❑ 5 GLASS LINING ❑ 6 UNLINED /// LINING 9s uNKNow❑ 99 OTHER IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL 7 YES D. CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 NYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION 5 CATHODIC PROTECTION 91 NONE 12,95 UNKNOWN 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 IF UNDERGROUND, BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION A < 2 R A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL A U 2 DOUBLE WALL A 5,11EEDNA U 95 UNKNOWN A U OTHE 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 6 CONCRETE A U 7 STEEL VW COATING A U 8 100% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN 99 -OTHER ro f7•C,.�� L D. LEAK DETECTION 1 AUTOMATIC LINE LEAK DETECTOR E 2 LINE TIGHTNESS TESTING MONITORING 99 OTHER V. TANK LEAK DETECTION ❑ 1 VISUAL CHECK❑ 2 VENTORY RECONCILIATION ❑ 3 VADOZE MONITORING ❑ 4 AUTOMATIC TANK GAUGING 5 GROUND WATER MONITORING !❑ 8 TANK TESTING 7 INTERSTITIAL MONITORING ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER VI. TANK CLOSURE INFORMATION 1. ESTIMATED DATE LAST USED (MO/OAYNR) 2. ESTIMATED QUANTITY OF 3. WAS TANK FILLED WITH SUBSTANCE REMAINING GALLONS INERT MATERIAL ? YES ❑ NO ❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY 4Atn rn rtuc Q=Cr nC av - - - CO -7ECT APPLICANTS NAME N -- - - - - - - • - - •— • — • • �•-•+ • .�. .., r n"w"L IJVC, IJ 1 UC AND If 4 SIGNATURE) DATE LOCAL AGENCY USE ONLY THE STATE I.D. NUMRFR Is cnluanccn AV TUC CAI 10 ulflkA GOC sal,.,.. STATE I.D.# COUNTY # JURISDICTION ar FACILITY x TANK n GA�v��&Y 2 �. D � PERMIT NUMBER PERMIT APPROVED 8Y—/D TATE PERMIT EXPIRAAATION DATE �3 (oho TiJIQ Cn Du �n ier ee ■nnn..n .....• /ly •• •••• v-+•1 o f A rCmmii ArrUGAI IUN - rUHM A, UNLE55 A CURRENT FORM A HAS BEEN FILED. • • Foaao~+SRs