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z�zounaea c STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B a COMPLETE A SEPARATE FORM FOR EACH TANK RVRTFM MARK ONLY Ev 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ON SITI ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ (6. TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: � A oS &A cYV' t4 ;?A -57f- `min , I V I. IAINNucaumi1'INN COMPLETE ALL ITEMS- SPECIFY IF UNKNnWN A. OWNER'S TANK I. D. # B. MANUFACTURED BY: Pr o n c i j In t L Djhb' A^ C. DATE INSTALLED (MO/DAYNEAR) oZ _a q -/ 0. TANK CAPACITY IN GALLONS: -'7 ( V 1/V I. IAINNG NI LN I, IFA -1 IS MARKED, COMPLETE ITEM C, A. 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM ❑ 3 CHEMICAL PRODUCT ❑ 4 OIL ❑ W EMPTYED ❑ 95 UNKNOWN ODUCT TE:12STE C ❑ la REGULAR �� 1b PREMIUNLEADM UNLEADED O 2 LEADED 3 ❑ 4 ❑ 5 ❑ g9 DIESEL ❑ 6 AVIATIONGAS GASAHOL JET FUEL ❑ 7 METHANOL OTHER (DESCRIBE IN ITEM O. BELOW) D. IF (A.1) IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED ❑ 2 SINGLE WALL C.A.S.#: ❑ 99 OTHER B. TANK M. TARN UUIN, I NUG I IUry AAe9K nuc isnn nniry inionvcc. e A. SYSTEM TYPE A U 1 SUCTION A. TYPE OF 101 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 Wl FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ B 100% METHANOL COMPATIBLE W/FRP (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING C. INTERIOR5 LINING ❑ GLASS LINING 6 UNLINED ❑ 95 UNKNOWN F-]99OTHER 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) A. SYSTEM TYPE A U 1 SUCTION A U V11 2 PRESSURE A U 3 GRAVITY ^ A U 99 OTHER B. CONSTRUCTION A U 1 SINGLEWALL A UO2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND CORROSION PROTECTION A U A U A U 1 BARESTEEL 5 ALUMINUM 9 GALVANIZED STEEL A U A U A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE (PVC) A U 6 CONCRETE A@7 STEEL W/ COATING A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 4 FIBERGLASS PIPE S 100% METHANOL COMPATIBLE W/FRP 99 OTHER D. LEAK DETECTION ❑ 1 AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING 3 MONROflING ❑ 99 OTHER V. TANK LEAK DETECTION ❑ 1 VISUAL CHECK INVENTORY RECONCILIATION ❑� ❑ 3 VADOZEMONITORING ❑ 4 AUTOMATIC TANK GAUGING ❑ 5 GROUNDWATER MONITORIN( F-]6 TANK TESTING /2 N;K7 INTERSTITIAL MONITORING ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER vI. 1 ANN uLVJUttC IINrVNMA I IUN 11. ESTIMATED DATE LAST USED(MO/DAYNR) 2. ESTIMATED QUANTITY OF 3. WAS TANK FILLED WITH SUBSTANCE REMAINING GALLONS INERT MATERIAL? VES ❑ NO❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANTME S NA APPLICANT'S (PRINTED eSIGNATURE) -- DATE LIJUAL AULNUY U,t UNLY THE STATE I.D. NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW STATE I.D.# COUNTY# JURISDICTION# FACILITY# TANK# PERMIT NUMBER I PERMIT APPROVED BV/DATE 11 1 PERMIT EXPIRATION DATE FORM B (7-91) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION • FORM A, UNLESS A CURRENT FORM A HAS BEEN FITTO FGROGM&R5