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STATE OF CALIFORNIA • a�', u.•9 - a STATE WATER RESOURCES CONTROL BOARD w W u u UNDERGROUND STORAGE TANK PERMIT APPLICATION • FORM B ,,, > o ¢r non N•r nnuel ere a QCDAMATP CORM FOR EACH TANK SYSTEM. w-11 MARK ONLY F71 NEW PERMIT ❑ ONE ITEM ❑ 2 INTERIM PERMIT ❑ ` 3 RENEWAL PERMIT 4 AMENDED PERMIT ❑ ❑ 5 CHANGE OF INFORMATION e TEMPORARY TANK{{ CLOSURE ❑ 7 PERMANENTLY CLOSED ONSITE ��TANK REMOVED of DBA OR FACILITY NAME WHERE TANK IS INSTALLED: Sze) S 31�t.c'ttp^ g�• inO� I. TANK DESCHIY I IUN COMPLETE ALL ITEMS- Srtldr T lr vnnnv.a. 1_ A OWNER'S TANK I D# Z B. MANUFACTURED BY: U K C DATE INSTALLED (MOIDAY/YEAR) ' l:J / D. TANK CAPACITY IN GALLONS: g� II. TANK CO NTS IFA -1 IS MARKED, COMPLETE ITEM C. rlrINU IINrunivIN I IVI\ IUIIL[.....-_.._..__.._._-- ❑ 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER i MOTOR VEHICLE FUEL ❑ 4 OIL I Iii Z SINGLE WALL 1111:1 C. ❑ 1&UNLEADED 3 DIESEL ❑ g AVIATION GAS 4 GASAHOL AGUI 2 PETROLEUM3 80 EMPTY 1 BARE STEEL 1 PRODUCT MIUM O 1bUL FADED ❑ 7 METHANOL ❑❑ 5 JET FUEL ❑ CHEMICAL PRODUCT O 95 UNKNOWN ❑ 5 CONCRETE 2 WASTE ❑ 2 LEADED 99 OTHER (DESCRIBE IN ITEM D. BELOW] D. IF (A.1) IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL C. A. S. #: 4D AND ALL THAT APPLIES IN BOX D AND III. TANK CUNSI KUL; IIUN MARK ONE I I tM UNLT IN MVA n, o, n, rlrINU IINrunivIN I IVI\ IUIIL[.....-_.._..__.._._-- ❑ 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN A. TYPE OF99 SYSTEM Iii Z SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTEDTANK) OTHER ❑ 2 PRESSURE A U 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/ FIBERGLASS REINFORCED PLASTIC B. TANK ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ED ALUMINUM ❑ 9 100% METHANOL COMPATIBLE W/FRP MATERIAL (PUmaryTAnk) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ W OTHER A U A U A U ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING C. INTERIOR ❑ 5 GLASS LINING ❑ 6 UNLINEDUNKNOWN MONITORING ❑ 99 OTHER LINING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO_ ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC D.CORROSION PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE 6 UNKNOWN ❑ 99 OTHER E. SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED (YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED (YEAR) IV. rlrINU IINrunivIN I IVI\ IUIIL[.....-_.._..__.._._-- A. SYSTEM TYPE A 1 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 A 1 BARE STEEL 5 ALUMINUM 9 GALVANIZED STEEL A U A U A U 2 STAINLESS STEEL A U 6 CONCRETE A U 10 CATHODIC PROTECTION 3 POLYCHLORIDE (PVC) A U 7 STEEL W/ COATING A U A U 95 UNKNOWN A U 4 FIBERGLASS PIPE 8 100% METHANOL COMPATIBLE W/FRP 99 OTHER D. LEAK DETECTION ❑ 1 AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TES TING ❑ MONITORING Egg OTHER J. TANK LEAK Ut I tG I IUN ❑ 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VADOZE MONITORING ❑ 4 AUTOMATIC TANK GAUGING ❑ 5 GROUNDWATER MONITORING ❑ 6 TANK TESTING ❑ 7 INTERSTITIAL MONITORING ORE ❑ 95 UNKNOWN ❑ 99 OTHER VI. TANK CLOSURE INFORMATION 1. ESTIMATED DATE LAST USED (MOY/YR) 2. ESTIMATED QUANTITY OF 3. WAS TANK FILLED WITH YES [7] NO T SUBSTANCE REMAINING GALLONS INERTMATERIAL? —11 1 IuC oCOT nC AAV WA1nWI FnrF IS TRUE AND CORRECT THIS GATE APPLICANTS NAME (PRINTED 6 SIGNATURE) LOCAL AGENCY USE ONLY THE STATE I.D. NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY # JURISDICTION # FACILITY # TANK # STATE I.D.# � S � 3 I L{ � 1 y% 1 PERMIT NUMBER PERMIT APPROVED BV/DATE PERMIT EXPIRATION DATE THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION • FORM A, UNLESS A CURRENT FORM A HAS BEEN FILED. FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS FORMS (12-91) 0 4Ai 1-71 FOR00148R6