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��° • STATE OF CALIFORNIA `�soVA STATE WATER RESOURCES CONTROL BOARD �� •, c�� UNDERGROUND STORAGE TANK PERMIT APPLICATION • FORM B �e nneeCi C C A ern .n.11 ....... ..... ... _.. _. _ c.. id: . I. IANKUtSL:HINIIVN COMPLETE ALL ITEMS-- SPECIFY IF UNKNOWN A. OWNERS TANK I. D.#AZ B. MANUFACTURED BY: Moo � N� C. DATE INSTALLED (MOIDAY YEAR) I a -Q 9 _ R 3 D. TANK CAPACITY IN GALLONS: 67(v b ILIANK UVN I tN I, IFA�I IS MARKED, COMPLETE ITEM C. A U SUCTION ^V❑ A, ❑ 1 MOTOR VEHICLE FUEL ❑ 4 OIL 2 PETROLEUM 80 EMPTY ❑ ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN B. 1 PRODUCT ❑ 2 WASTE C la REGULAR 1b PREMIUM ❑ 2 LEADED D 3 DIESEL ❑ 6 AVIATIONGAS 4 GASAHOL L]7 METHANOL ❑ 5 JET FUEL ❑ 99 OTHER (DESCRIBE IN ITEM D. BELOW) D. IF (A.1) IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED ❑ 2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) C. A. 1. iruvnbvnArnV AVIV MARKONE ITEM ONLYIN BOXESA B ANDC AND ALLTHAT APPLIES IN Iv. rIrmu IINrunNIA11VN CIRCIL eIFeenv[neni A. SYSTEM TYPE A U SUCTION ^V❑ 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 ❑ 3 FIBERGLASS 4 STEEL CLAD W/ FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 10,% 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. INTERIOR LINING ❑ 5 GLASS LINING �6 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? VES _ 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. rIrmu IINrunNIA11VN CIRCIL eIFeenv[neni A. SYSTEM TYPE A U SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B. 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 A U A U 1 BARE STEEL 5 ALUMINUM 9 GALVANIZED STEEL A U A U A U 2 STAINLESS STEEL A U 6 CONCRETE AO7 10 CATHODIC PROTECTION 3 POLYVINYL CHLORIDE (PVC) A U STEEL W/COATING A U A U 95 UNKNOW A U 4 FIBERGLASS PIPE 8 100% METHANOL COMPATIBLE W/FRP 99 OTHER O. LEAK DETECTION ❑ 1 AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING J MONRORING ❑ 99 OTHER V. TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VADOZE MONITORING ❑ 4 AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING ❑ 6 TANK TESTING Y�7 INTERSTITIAL MONITORING ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER vI. IAINK %,LVAUHC INrUHMA ITVN t ESTIMATED GATE LAST USED (MO/DAVnR) 2' ESTIMATED QUANTITY OF SUBSTANCE REMAINING GALLONS S WASITANK FILLED NERT MATERIALI? YES ❑ NO ❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNowI Fnr= IC T011C A A1n nnn APPLICANTS NAME (PRINTEDa SIGNATGRE rA. \ DATE LUt.AL Ali L NUT UJt ONLY THE STATE I.D. NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY# TANK It STATE LDA COUNTY PERMITNUMBER PERMIT APPROVED BY/DATE PERMITEXPIRATI NNDDATE 'ORM B (7-91) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION • FORM A, UNLESS A CURRENT FORMA HAS BEEN' ?ECT FORORKB41S I (V