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STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B COMPLETE A SEPARATE FORM FOR EACKTANK SYSTEM MARK ONLY F7 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT 6 TEMPORAR ANK I D8A OR FACILITY NAME WHERE TANK IS INSTALLED: Al2f 0 Fj:4L moo. SL4�E;; 7 RMANENTLY CLOSED ONSITE a NK REMOVED I. TANK DESCRIPTION COMPLETE ALL ITEMS - SPECIFY IF UNKNOWN ' A. OWNER'S TANK I. D. ;r 2 _ V 1'j L-- 2 I S. MANUFACTURED BY: C. DATE INSTALLED (MO/DAY/YEAR) to /- / $ � D. TANK CAPACITY IN GALLONS: `Z Q OO II. TANK CONTENTS IFA -1 ISMARKED. COMPLETE ITEM C. A. ❑,, 1 MOTOR VEHICLE FUEL 4 OIL B. C. E aRUNLEADEDLAR3 DIESEL El AVIATION GAS ❑ 2 PETROLEUM 80 EMPTY Ell 1 PRODUCT a lb PREMIUM UNLEADED 5 JETFUEL `— 4 GASAHCL 11 7 METHANOL ❑ ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN 2 WASTE 2 LEADED ❑ 99 OTHER (DESCRIBE IN ITEM D. BELCW) D. IF (A.1) IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C. III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A, S. 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 SYSTEM ❑ 2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER B. TANK ❑ 1 BARE STEEL ❑ 2 STAINLESS STEEL C✓ 3 FIBERGLASS ❑ 4 STEEL CLAD W/ FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM a 8 1009/ METHANOL COMPATIBLE W%FRP (Primary Tank) a 9 BRONZE 10 GALVANIZED STEEL ❑ 95 UNKNOWN a 99 OTHER ❑ 1 RUBBER LINED 2 ALKYD LINING 3 EPDXY LINING ❑ 4 PHENOLIC LINING C. IP LINING ❑ 5 GLASS LINING ❑� UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES _ NO_ D. CORROSION ❑ 1 POLYETHYLENE WRAP 2 COATING PROTECTION ❑ 5 CATHODIC PROTECTION 91 NONE E. SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED (YEAR) 19 Sri ❑ 3 VINYL WRAP ❑✓ 4 FIBERGLASS REINFORCED PLASTIC ❑ 95 UNKNOWN ❑ 99 OTHER OVERFILL PREVENTION EQUIPMENT INSTALLED (YEAR) IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND, BOTH IF APPLICABLE ❑ 2 INVENTORY RECONCILIATION D? -'7 INTERSTITIAL ❑ 3 VADOZE MONITORING ❑ 4 AUTOMATIC TANK GAUGING A. SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER S. 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 CORROSION PROTECTION A U 1 BARE STEEL A U 5 ALUMINUM A U 9 GALVANIZED STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE (PVC) A 04 A U 6 CONCRETE A U 7 STEEL W/ COATING A U A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U FIBERGLASS PIPE 8 100% METHANOL COMPATIBLE W,FRP 99 OTHER D. LEAK DETECTION ❑ 1 AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING ❑ IN S I A MONrroRING ❑ 99 OTHER V. TANK LEAK DETECTION 1 VISUAL CHECK 6 TANK TESTING ❑ 2 INVENTORY RECONCILIATION D? -'7 INTERSTITIAL ❑ 3 VADOZE MONITORING ❑ 4 AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING PERMIT NUMBER MONITORING El 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER VI. 1 ANN GLUJUHt ft-UHMATION 1. ESTIMATED DATE LAST USED (MO/DAY/YR) I 2. ESTIMATED QUANTITY OF 3. WAS TANK FILLED WITH SUBSTANCE REMAINING GALLONS INERT MATERIAL ? YES a NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANT'S NAME (PRINTED d SIGNATURE) _ DATE LOCAL AG ENCY USF ON[ Y THE STATE 111 NI IMG1tD IQ lY1MPooCn - --- - STATE I.D.# C --••••-^-• I�;Cj •� +�••� vI In vvvnl4ulvl0r MJDtLUW COUNTY x JURISDICTION x FACILITY x TANK x EEHHYIS,II�� r� PERMIT NUMBER PERMIT APPROVED BY/DATE I PERMIT —EXPIRATION DATE rvnm o li-y I) , "•+ .+nn, nwa1 oc MVLVUWAMC'J D i A rttl IV11I ArrLIGAIIUN • FUHN1 A, UNLESS A CURRENT FORMA HAS BEE!/FILE'D. FOROGUB.Rs r.1