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STATE OF CALIFORNIA °O STATE WATER RESOURCES CONTROL BOARD 3y UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B u �� o COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT �5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ON aL ONE ITEM 7_12 INTERIM PERMIT 714 AMENDED PERMIT F76 TEMPORARY TANK CLOSURE $ TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: I. TANK DESCRIPTION COMPLETE ALL ITEMS - SPECIFY IF UNKNOWN A OWNER'S TANK I. D. # 2 B. MANUFACTURED BY: UNKNOWN C. DATE INSTALLED (MO/DAYNEAR) UNKNOWN D. TANK CAPACITY IN GALLONS: 8,000 II. TANK CONTENTS IF A-1 IS MARKED, COMPLETE ITEM C. A. Fx_l 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C. P� to REGULAR UNLEADED ❑ 3 DIESEL ❑ 6 AVIATION GAS ❑ 2 PETROLEUM ❑ 80 EMPTY ® 1 PRODUCT a 1b PREMIUM UNLEADED ❑ 4 GASAHOL ❑ 7 METHANOL F71c MIDGRADE UNLEADED F75 JET FUEL F78 M85 ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED ❑ 99 OTHER (DESCRIBE IN ITEM D. BELOM 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 APPLIES IN BOX D AND E A. TYPE OF ❑ 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 5 INTERNAL BLADDER SYSTEM ❑ 95 UNKNOWN SYSTEM 2 SINGLE WALL ❑ 4 SINGLE WALL IN A VAULT 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 F7 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP (Primary Tank) 9 BRONZE LL❑�- ❑ 10 GALVANIZED STEELx 95 UNKNOWN ❑ 99 OTHER C. INTERIOR 1 RUBBER LINED172 ALKYD LINING EPDXY LINING 4 PHENOLIC LINING LINING OR 715 GLASS LINING El UNLINED rrrYvvv❑--ttt'\3 95 UNKNOWN �❑/ �'I 99 OTHER I a\p �` COATING IS LINING MATERIAL COMPATIBLE WITH 10D°k METHANOL? YES — NO— 1 MECHANICAL UNE LEAK fa D. EXTERIOR ❑ 1 POLYETHYLENE WRAP 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC CORROSION PROTECTION El CATHODIC PROTECTION ❑ 91 NONE K7 95 UNKNOWN �} ❑ 99 OTHER E. SPILL AND OVERFILL, BiC. SPILL CONTAINMENT INSTALLED (YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED (YEAR) DROP TUBE YES NO STRIKER PLATE YES NO DISPENSER CONTAINMENT YES NO IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND, BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION A® 2 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH AQ 95 UNKNOWN A U 99 OTHER C. MATERIAL AND A U 1 BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE (PVC) A U 4 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL W/ COATING A U 8 100% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A095 UNKNOWN A U 99 OTHER D. LEAK DETECTION 1 MECHANICAL UNE LEAK fa 2 LINE TIGHTNESS [:]3 CONTINUOUS INTERSTITIAL O 4 ELECTRONIC UNE ❑ 5 AUTOMATIC PUMP [:]99 OTHER DETECTOR LTJ TESTING MOMTORWG LEAK DETECTOR SHUTDOWN V. TANK LEAK DETECTION F7 1 VISUAL CHECK 1:12 MANUAL INVENTRECONCILIATIONORY ❑ 3 MONIITORING VAOZE � 4 AUTOMATGAUGING IC TANK ❑ 5 MONITORING GROUND WATER ❑ 6 TESTINGANNUAL ❑ 7 MONITORING CONTINUOUS INTERSTITIAL [:]8 SIR ❑ 9 WE GAUGING ❑ 70 MOSTTHLY TANK ❑ 95 UNKNOWN NG ❑ 99 OTHER VI. TANK CLOSURE INFORMATION (PERMANENT CLOSURE IN-PLACE) 1. ESTIMATED DATE LAST USED (MO/DAY/YR) 2. ESTIMATED QUANTITY OF 3, WAS TANK FILLED WITH YES ❑ NO ❑ SUBSTANCE REMAINING GALLONS INERT MATERIAL ? THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT TANK OWNER'S (PRINTED& SIGNATURES E /VI" �/'7�� - ^" ^ OP4A4 0A DATE 3,2-1-,97 LOCAL AGENCY USE ONLY THE STATE I.D. NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY # JURISDICTION # FACILITY # TANK # U STATE I.D.# m = I D I Q 0 PERMIT NUMBER PERMIT APPROVED BYIDATE PERMIT EXPIRATION DATE 4 - THIS FORM MUST BE ACCOMPANIED BY A PERMIT APP SHOULD BE ACCOMPANIED BY A PLOT E. FORM B (6-95) ON - FORM A, UNLESS A CURRENT FORM A HAS BEEN FILED. C MUST BE COMPLETED FOR INSTALLATIONS. THIS FORM -1LE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING T-RGROUND STORAGE TANK REGULATIONS