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-c" STATE STATE OF CALIFORNIA P P `Oti STATE WATER RESOURCES CONTROL BOARD 3c 'd UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B a0 COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM, MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT B. MANUFACTURED BY: e+' S 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ONSITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED / ❑ 2 STAINLESS STEEL 3 FIBERGLASS ❑ 4 STEEL CLAD W/ FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE DBA OR FACILITY NAME WHERE TANK IS INSTALLED:C-k"row ❑ 7 ALUMINUM S 1 % S- (Primary Tank) ❑ 9 BRONZE 1. I. TANK DESCRIPTION COMPLETE ALL ITEMS-- SPECIFY IF UNKNOWN A. OWNER'S TANK I. D. # 3 B. MANUFACTURED BY: e+' S C. DATE INSTALLED (MO/DAY/YEAR) tj 19 3 D. TANK CAPACITY IN GALLONS: t o O 0 ILTANKCONTENTS IFA -1 IS MARKED. COMPLETE ITEM C. A. 1 MOTOR VEHICLE FUEL ❑ 4 OIL g, la REGULAR EGUL R 3 DIESEL C. ❑ ❑ 6 AVIATION GAS UNLEA❑ 2 PETROLEUM ❑ 80 EMPTY 1 PRODUCT tb PREMIUM ❑ 4 GASAHOL ❑ 7 METHANOL UNLEADED ❑ 5 JET FUEL ❑ 3 CHEMICAL PRODUCT ❑ 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. #: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A. B. AND C. AND ALL THAT APPI IFS IN Rnx n ANn G A. TYPE OF ❑ 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM K 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 ❑ 8 100% 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. INTERIOR LINING ❑ 5 GLASS LINING6 UNLINED F--]95 UNKNOWN ❑ 99 OTHER IS LINING MATERIAL COMPATIBLE WITH 1001/ METHANOL? YES_ NO D. CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP,n/ 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) i IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND. BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION A(f) 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A 6) 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 1 BARE STEEL A U 5 ALUMINUM A U 9 GALVANIZED STEEL A U 2 STAINLESS STEEL A U A U 6 CONCRETE A U A U 10 CATHODIC PROTECTION 3 POLYVINYL CHLORIDE (PVC) A to 4 FIBERGLASS PIPE 7 STEEL W/COATING A U 8 1009/6 METHANOL COMPATIBLE W/FRP A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION � 1 AUTOMATIC LINE LEAK DETECTOR 2 LINE TIGHTNESS TESTING ❑ 3 INTERSMONITTITIAL [::199 OTHER V. TANK LEAK DETECTION ❑ 1 VISUAL CHECK ® 2 INVENTORY RECONCILIATION 3 VADOZE MONITORING ❑ 4 AUTOMATIC TANK GAUGING ❑ 5 GROUNDWATER MONITORING 6 TANK TESTING ❑ 7 INTERSTITIAL MONITORING C 91 NONE ❑ 95 UNKNOWN 99 OTHER S ( p VI. TANK CLOSURE INFORMATION 1. ESTIMATED DATE LAST USED (MO/DAY/YR) 2. ESTIMATED QUANTITY OF 3. WAS TANK FILLED WITH YES ❑ NO EMA SUBSTANC INING GALL NS INERT MATERIAL? THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJ Y, A T T BES Y OWLEDGE, IS TRUE AND CORRECT APPLICANTS NAMEDATE (PRINTED B SIGNATURE) D'Aq �� - �-O (/-0�LLL �� \ `-7� - I LOCAL AGENCY USE ONLY THE STATE I.D. NUMBER IS COMPOSED OF THE FOU NUMBER BELOW COUNTY # JURISDICTION # FACILITANK # STATE I.D.# FFG PERMIT NUMBER PERMIT APPROVED BY/DATE 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 F ED. FOR0034B