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y VR ♦4 STATEOFCAUFORMA STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B COMPLETE A SEPARATE FORM FOR VCH TANK SYSTEM — MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT S CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ONSITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 8 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED /�'� DBA OR FACILITY NAME WHERE TANK IS INSTALLED: I VAkIV INEMP0IGTI09M —110 IT...- CPlIPV IF IINKNOWN A. OWNER'S TANK I.D.# / B. MANUFACTURED BY: C. DATE INSTALLED (MO�DAY/YEAR)� D. TANK CAPACITY IN GALLONS: B TAAIVrl1MTLATFC Or A_ 4RUAPVPn muPI ITFMC J A ❑ 1 MOTOR VEHICLE FUEL 4 OIL B. C. ❑ 1aIRIEGGUA R DED n 4 DIESEL L�❑JI OL ❑ S AVIATION GAS ❑ 2 PETROLEUM ❑ 80 EMPTYPRODUCT SYSTEM ❑ 1bUN EAIDEO 5 JET FUEL 0 7 METHANOL ❑ 3 CHEMICALPRODUCT ❑ 95 UNKNOWN 2 WASTE ❑ 2 LEADED ❑ 99 OTHER (DESCRIBE IN ITEM D. BELOW) D. IF (A.1) IS NOT MARKED. ENTER NAME OF SUBSTANCE STORED C. A. S.0: III TAMV rT1MCTPIICTinM ueov nuF RCVl1NIVIN MYFR4RANDC ANn AIITHATAPPIIFSIN90Xn A. TYPE OF ❑ 1 DOUBLE WALL ❑ 33 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM ❑ 2 SINGE WALL Fl; 4 SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER CONSTRUCTION 1 BARE STEEL 02 STAINLESS STEEL F-13 FIBERGLASS ❑ 4 STEEL CUD W/ FIBERGLASS REINFORCED PLASTIC B. TANK MATERIAL ❑ 5 CONCRETE ❑ S POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ S 100% METHANOL COMPATBLE W/FRP (Pdmary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINEDn 2 �I.KVD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING C. INTERIOR ❑ 5 GLASS LINING Lk� S/UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER LINING 7 STEEL W/ COATING A B 100% METHANOLCO )BLE /FRP PROTECTION A U 9 GALVANIZED STEEL IS LINING MATERIA COMPATIBLE WITH 100%METHANOL7 YES_ NO— A U 95 UNKNOWN U 99 O R D. CORROSION ❑ I POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION f�j- 91 NONE F-195 UNKNOWN ❑ 99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND. BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION �UA PRESSURE A U 3 GRAVITY A U 99 OTHER S. CONSTRUCTION SINGE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER A U I BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE (PVC) A U 4 FIBERGLASS PIPE C. MATERIAL AND CORROSION A U 5 ALUMINUM A U B CONCRETE A U 7 STEEL W/ COATING A B 100% METHANOLCO )BLE /FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN U 99 O R D. LEAK DETECTION ❑ 1 AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING ❑ 0 MONITORmG 99 OTHER I. TANK AK DETECTION 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VAPOR MONITORING ❑ 4 AUTOMATIC TANK GAUGING ❑ 5 GROUNDWATER MONITORING ❑ 8 TANKTESTING ❑ 7 INTERSTITIAL MONITORING ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER 1lify,MATED DATE LAST USED (MO/DAV/VR) I SUN 2 ESTIMATED BSTANCE REMAINING GALLONS I 3 W INERT MATERIAL 7N YES ❑ NO ❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANTS NAME DATE (PRINTEP6SIGWII , LOCAL AGENCY USE ONLY THE STATE I.D. NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOA,- COUNTY # JURISDICTION # FACIL TANK # STATE I.D.# PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE FORM B (9-90) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION • FORM A, UNLESS A CURRENT FOR/M' A HAS BEEN FILED. ,� 7 - 7 FORDD B