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J\kL- STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B /A COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ❑ i NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATIONRMANENTLY TE ONE REM ❑ 2 INTERIM PERMIT ❑ d AMENDED PERMIT 6 TEMPORARY TANK CLOSURE 8 TANK REM D DBA OR FACILITY NAME WHERE TANK IS INSTALLED: I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A. OWNER'S TANK I.D.# B. MANUFACTURED BY: �7 C. DATE INSTALLED(MQdDAY/YEAR) L4-VL-or-e—D. TANK CAPACITY IN GALLONS: %moi II. TANKCONTFNTS A. ❑ 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM ❑ 3 CHEMICAL PRODUCT 4 OIL ❑ BO EMPTY ❑ 95 UNKNOWN 8. ❑ I PRODUCT 2 WASTE G ❑ IAUN GLEADED ❑ 1b PREMIUM UNLEADED ❑ 2 LEADED 3 DIESEL El S AVIATIONGAS 4 GASANOL ❑ 7 METHANOL 5 JET FUEL 99 OTHER (DESCRIBE IN ITEM D. BELOW) SINGLE WALL D. IF (A.1) IS NOT MARKED. ENTER NAME OF SUBSTANCE STORED LV A C&44 B. TANK 1 BARE STEEL C. A. S. # : 05 - ❑ 4 STEEL CLAD W/ FIBERGLASS REINFORCED PLASTIC Ill. TANK CONSTRUCTION MARKMPITCMnN,YlMRnY.CA o sunt A. TYPE OF 1-71 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM2 SINGLE WALL ❑ d 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 ❑ 8 POLYVINYL CHLORO ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP (PHMWYTN*) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 05 UNKNOWN ❑ 09 OTHER ❑ 1 RUBBER LINED❑/2 ALKYO LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING C. INTERIOR F75 GLASS LINING DGL S UNLINED ❑ % UNKNOWN ❑ 99 OTHER LINING /`�� IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO -K D. CORROSION ❑ I POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION;<91 NONE ❑95 UNKNOWN ❑ 90 OTHER E SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED (YEAR) OVERFILL PREVENTION ECUIPMENT INSTALLED (YEAR) IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND. BOTH IF APPLICABLE A SYSTEM TYPE A U / SUCTION A U 2 PRESSURE kq&3 GRAVITY A U 90 OTHER B. CONSTRUCTION A V 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 A A U 11 BARE STEEL 5 ALUMINUM 9 GALVANIZED STEEL A U A U A U 2 STAINLESS STEEL A U a CONCRETE A U 10 CATHODIC PROTECTION 3 POLYVINYL CHLORIDE (PVC) A U 4 FIBERGLASS PIPE 7 STEEL W/COATNG A U 8 100% METHANOL COMPATIBLE W/FRP A U 96 UNKNOWN A U 90 OTHER D. LEAK DETECTION ❑ 1 AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING ❑ MONW OTHER ORI V. TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VADOZE MONITORING ❑ 4 AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER{ MONITORING ❑ S TANK TESTING F77 INTERSTITIAL MONITORING ❑ 91 NONE ❑ 95 UNKNOWN �99 OTHER -rd 111Ko%Gl 1. ESTIMATED DATE LAITUSED (MO/DAYNR) 2. ESTIMATED QUANTITY OF 13. WAS TANK FILLED WITH --EhT SUBSTANCE REMAINING QALLONS INERTMATERIALP Y ❑ �❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT (PRIKIE9s SM ATJRP THE STATE I.D. NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW Zpc -L D ;,,- 3 f D { 1— o COUNTY # JURISDICTION # FACILITY # TANK # . STATE I.D.# THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION - FORM A, UNLESS A CURRENT FORM A HAS BEEN FILED. ' FILE THIS FORM WITH "'O LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STr- • ;E TANK REGULATIONS FORM 0 (12-91) t. r6 - FORD) 6BA6