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STATE OF CAUFORMA s STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION • FORM B 0 �•4.pny' COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY 1 NEW PERMIT ❑ J RENEWAL PERMIT 5 CHANGE OF INFORMATION r 7 PERMANENTLY CLO SI ONE REM I❑ 2 INTERNA PERMIT ❑ d AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED / J � DBA OR FACILITY NAME WHERE TANK IS INSTALLED: C)A"roti # QO j y I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A. OWNERS TANK 1.0.A B. MANUFACTURED BY: fcc✓ C. DATE INSTALLED(MO/OAYNEAR) I 4 Q 0. TANK CAPACITY IN GALLONS: I C CCC ILTANKCONTENTS IF MI IS MARKED.COMPLETE ITEM C. �' A. 1 MOTOR VEHICLE FUEL ❑ A OIL B. G ❑ tAUNLEAOED REG y DIESEL ❑ 8 AVIATIONGAS ❑ 2 PETROLEUM ❑ 80 EMPTY Q 1 PRODUCT IDPREMIUM �LLii GAS7 METHANOL ❑ 0 CHEMICAL PRODWT ❑ 95 UNKNOWN ❑ 2 WASTE Q 2 UNLEADED D " Fij�gy/O ERL(OESCRGE IN ITEM 0. BELOW( 0. F(A.1)0 NOTMARKED. ENTER NAME OF SUBSTANCE STORED (us llKle.g�e C.A.S.#: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.S.AND C.AND ALL THAT APPLIES IN BOX D AND A. TYPE OF 1 DOUBLE WALL ❑ 0 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM ❑ 2 SINGLE WALL ❑ A SECONDARY CONTAINMENT (VAULTED TANK) ❑ 90 OTHER B. TANK ❑ I BARE STEEL ❑ 2 STAINLESS STEEL ❑ 0 FIBERGLASS a STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 8 POLYVINYL CHLORIDE 7 ALUMINUM 8 I(XI% METHANOL COMPATIBLE W/FRP (PdmwyTmk) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER 1 RUBBER LINED ❑ 2 AL KYO LINING S EPDXY LINING A PHENOLIC LINING C.INTERIOR ❑ 5 GLASS LINING 8 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER LINING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ 40_ O.CORROSION ❑ i POLYETHYLENE WRAP 'd 2 COATING 0 VINYL WRAP ❑ s FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ S CATHODIC PROTECTION ❑ 91 NONE 95 UNKNOWN j 99 OTHER I E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR) iG!O I�OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) 1 1.9 J IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND.BOTH IF APPLICABLE A. SYSTEM TYPE A& 1 SUCTION A U 2 PRESSURE A U D GRAVITY A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL A � 2 DOUBLE WALL A U 2 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND A U 1 BARE STEEL A U 2 STAINLESS STEEL A U S POLYVINYL CHLORIDE(PVC)A U A FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 8 CONCRETE A& 7 STEEL W/COATING A U 8 100% METHANOL COMPATIBLE WIFRP PROTECTION A u 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER 0. LEAK DETECTION ❑ 1 AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING MONRORWG ❑99 OTHER V.TANK LEAK DETECTION (❑ I VISUAL CHECK 2 INVENTORY RECONCILIATION ❑ S VADOZE MONITORING ❑ A AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING I❑ 6 TANK TESTING 7 INTERSTITIALMONRORING ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION 1.ESTIMATED DATE LAST USED NO/O/LV/YR) 2.ESTIMATED OUANTITY OF 2.WAS TANK FILLED WITH YES C] NO❑ SUBSTANCE REMAINING GALL�NS ERT MATERIAL? tJ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF P ,AN O BES KNOWLEDGE. IS TRUE AND CORRECT APPLICANTS NAMEDATE (PRINTED 8 SKWATUp R �.v�o �. 5 • 0 soa 9-/'4 -93 LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR UM RS BELOW,/ 7 C�OUNTY x JURISDICTION 9 FA� TANK x I]' STATE 1041 J 1 1 1 11 1 F/ PERMIT NUMBER I PERMIT APPROVED BYITIATE PERMIT EXPIRATIONOATE 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 FORM B (12-91) ^ FORMASM