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pCboq.. CO STATE OFCAUFORt'pA � �e STATE WATER RESOURCES CONTROL BOARD w °m UNDERGROUND STORAGE TANK PERMIT APPLICATION • FORM B COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. -Q = MARK ONLY 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION 0 7 PERMANENTLY CLOSED ON SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: GO q- — SerlA E::]4 STEEL CLAD W/ FIBERGLASS REINFORCED PLASTIC tj--- Com'-TAk-Ttcwj 3 POLYVINYL CHLORIDE (PVC) A U 4 FIBERGLASS PIPE 1. TANK DESCRIPTION COMPLETE ALL ITEMS -- SPECIFY IF UNKNOWN A. OWNER'S TANK I. D. # U0I<c il,W 0 k. 1 B. MANUFACTURED BY: Lj Iwo !.� C. DATE INSTALLED (MO/DAY/YEAR) IN (A D. TANK CAPACITY IN GALLONS: _ IL TANK CONTENTS IFA -1 IS MARKED. COMPLETE ITEM C. A. 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. -PRODUCT C. ❑ la REGULAR 6 AVIATION GAS ❑ 4 DIESELGASAHL ❑ ❑ 2 PETROLEUM ❑ 80 EMPTY EL/ �UPRE NL MIU D ❑ 5 JET FUEL ❑ 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. # 111_ TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A. R. AND C. AND ALL THAT APPLIES IN ROX D A. TYPE OF ❑ 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER 95 UNKNOWN SYSTEM ❑ 2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) [:j 99 OTHER A U 2 DOUBLE WALL A U F—]1 BARE STEEL 0 2 STAINLESS STEEL F—]3 FIBERGLASS E::]4 STEEL CLAD W/ FIBERGLASS REINFORCED PLASTIC B. TANK 3 POLYVINYL CHLORIDE (PVC) A U 4 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑7 ALUMINUM ❑ 8 100°/ METHANOL COMPATIBLE W/FRP A U 10 CATHODIC PROTECTION A& 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION ❑ 1 AUTOMATIC LINE LEAK (Primary Tank) 0 9 BRONZE E::]10 GALVANIZED STEEL 95 UNKNOWN ❑ 99 OTHER MONITORING 0 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING C. INTERIOR ❑ 5 GLASS LINING ❑ 6 UNLINED 95 UNKNOWN ❑ 99 OTHER LINING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO D. CORROSION F-� 1 POLYETHYLENE WRAP ❑ 2 COATING 03 INYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION 0 5 CATHODIC PROTECTION ❑ 91 NONE 95 UNKNOWN ❑ 99 OTHER IV. PIPING INFORMATION CIRCLE A IFABOVEGROUNDOR U IF UNDERGROUND. BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION A ®2 PRESSURE A U 3 GRAVITY A U99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A 095 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 6 CONCRETE A U 7 STEEL W/ COATING A U 8 100°/ METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A& 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION ❑ 1 AUTOMATIC LINE LEAK DETECTOR D 2 LINE TIGHTNESS TESTING 3 INTERSTITIAL g OTHER ;JOY -&10140 0 MONITORING V. TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VAPOR MONITORING ❑ 4 AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING ❑ 6 TANK TESTING '❑ 7 INTERSTITIAL MONITORING ❑ 91 NONE 95 UNKNOWN ❑ 99 OTHER VI. TANK CLOSURE INFORMATION 1. ESTIMATED DATE LAST USED (MO/DAY/YR) 2. ESTIMATED QUANTITY OF SUBSTANCE REMAINING 3. WAS TANK FILLED WITH YES NO ❑ Iuj. eckbwi L1► kAoWIJ GALLONS INERT MATERIAL? THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANTS NAMEDATE (PRINTED& SIGNATURE)R� 7M(5�LCA � GrS T ti/_ C�.,�� LOCAL AGENCY USE ONLY THE STATE I.D. NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW T COUNTY # JURISDICTION # FACILITY # TANK # STATE I.D.# m 1❑ PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE FORM B (9.90) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION • FORM A, UNLESS A CURRENT FORM A HAS BEEN FILED. FOR00348-144