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� " K << ' ad Ti i�l`c to i Ln STATE OF CALIFORNIA �I `"'STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B ° PIA, z' V COMPLETE A SEPARATE FORM FOR ACH TANK SYSTEM. O H,. MARK ONLY ❑ 1 NEW PERMIT3 ❑ ONE ITEM ❑ 2 INTERIM PERMIT ❑ RENEWAL 4 AMENDED PERMIT PERMIT 5 CHANGE Of INFORMATION ❑ ] PERMANENTLY CLOSE TE ❑ 6 TEMPORARY TANK CLOSURE W, TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: I. TANK DESCRIPTION COMPLETE ALL ITEMS- 20 SPECIFY IF uurunwu cam— A. OWNER'S TANK I.D.# B. MANUFACNRED BV: C. DATE INSTALLED(MO/DAYIYEAR) /,isAIL, v D. TANK CAPACITY IN GALLONS: A. SYSTEM TYPE1 o MNMRtU, uuyeLE IE I TEM C. E A. TYPE OF 2 PRESSURE U ❑ 3 SINGLE WALL WITH EXTERIOR LINER © 95 UNKNOWN A. ❑ 1 2 ❑ 3 D. IF (A.1) IS MOTOR VEHICLE FUEL PETROLEUM CHEMICAL PRODUCT NOT MARKED, ENTER NAME 4 OIL ❑ W EMPTY ❑ 95 UNKNOWN OF SUBSTANCE STORED B. �i PRODUCT ❑ 2 WASTE 0. ❑ 1aUNLEALAI'DED 3 ❑ 1b PREMIUM 4 2 LEADEDED ❑ 5 ❑ �99 DIESEL ❑j 6 AVIATION GAS GASAHOL ❑:] METHANOL JET FUEL OTHER (DESCRIBE IN ITEM D. BELOW) 111 Tl1\IV Pn�IA.Tnunr�nu ❑ 3 FIBERGLASS ❑ 4 STEELCLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ® 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM A. SYSTEM TYPE1 ❑ 1 DOUBLE WALL E A. TYPE OF 2 PRESSURE U ❑ 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 STEELCLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ® 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ B 100% METHANOL COMPATIBLE W/FRP (PrimaryTank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER C INTERIOR ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING LINING ❑ 5 GLASS LINING ❑ 6 UNLINED ®. 95 .UNKNOWN ❑ 99 OTHER IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO_ D. CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE ® 95 UNKNOWN ❑ 99 OTHER E. SPILL AND OVERFILL - SPILL CONTAINMENT INSTALLED (YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED (YEAR) IV DIDIM!_ INICn0RAA7Inu - - A. SYSTEM TYPE1 A U 2 PRESSURE U irnrrLlU bl-t GRAVITY A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A&1795 UNKNOWN A U 99 OTHER C. MATERIAL AND CORROSION PROTECTION D. LEAK DETECTION A U A U A U ❑ 1 1 BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE (PVC)A U 4 FIBERGLASS PIPE 5 ALUMINUM A U 6 CONCRETE A U 7 STEELWICCATING A U 8 100% METHANOL COMPATIBLEW/FRP 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A tr>5 UNKNOWN A U 99 OTHER AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING ❑3 MONRORING❑ 99 OTHER_ �f7p^y� V TANK LEAK DET ❑ 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VADOZE MONITORING ❑ 4 AUTOMATIC TANK GAUGING ❑ 5 GROUNDWATER MONITORING ❑_6 TANK TESTING ❑ 7 INTERSTITIAL MONITORING L�ii-91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER VI. TANK CI nSIIPP IMPn DeSATInkI ESTIMATED DATE LAST USED MO/DAY/YR) 2. ESTIMATED QUANTITY OF 3. WAS TANK FILLED WITH kN SUBSTANCE REMAINING GALLONS I INERTMATERIAL7 YES ❑ NOX v `ORM ' Oiv�ri ED UNDER PEN�OERJURY, AND TO THE, T OF MY KNOWLEDGE, IS APPI C TRUE AND CORRECT LOCAL AGENCY USE ONLY THE STAAEI.D. N ER IS COMPOSED bF o ELOW COUNTY It JURISDICTION# FACILITY# (TANK# STATE I.D.# / V� �z�� ZT� I %� (PERMIT NUMBER PERMITAPPROVEDBY/DATE, C3ov PRMITEXPIRAI( 1 n FORM B (7-91) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION • FORM A, UNLESS A CURRENT FORM A HAS BEEN FILED. - 48 V FOR003411-115