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pC STATE OF CALIFORNIA •'pec � ^ STATE WATER RESOURCES CONTROL BOARD i 'o UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B w �� e w, ; COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. cA"'°""�� MARK ONLY 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ONSITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ B TANK REMOVED ©' DBA OR FACILITY NAME WHERE TANK IS INSTALLED: 2--+ 5 (I`� WOT r ILV F3 ST ❑ 99 OTHER (DESCRIBE IN ITEM D. BELOW) D. IF (A.1) IS NOT MARKED, ENTER NAME I. TANK DESCRIPTION COMPLETE ALL ITEMS-- SPECIFY IF UNKNOWN A. OWNERS TANK I. D.a 2 ❑ 4 OIL B. B. MANUFACTURED BY: UK n IL`�1 3 DIESEL ❑ 6 AVIATION GAS 4 GASAHOL C. DATE INSTALLED (MO/DAYIYEAR) U K PRODUCT i D. TANK CAPACITY IN GALLONS: 10 PnO II. I ANK CON I EN I S IFA -11S MARKED, COMPLETE ITEM A. 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C. e REGULAR UNLEADED n IL`�1 3 DIESEL ❑ 6 AVIATION GAS 4 GASAHOL F--]2 PETROLEUM ❑ 90 EMPTY PRODUCT ❑ lb PREMIUM ❑ 7 METHANOL F–]3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE UNLEADED ❑ 2 LEADED E] 5 JETFUEL ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ S 100% METHANOL COMPATIBLE W/FRP (PrimaryTank) ❑ 99 OTHER (DESCRIBE IN ITEM D. BELOW) D. IF (A.1) IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED ❑ 99 OTHER C. A. s. s: III. TANK CONSTRUCTION MARK nNF ITPURINI V IN GIIYCC A o ANTI AMn Ali TIJAT Av131r«-15— A. TYPE OF 11 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM F❑ LJ 2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER B. TANK BARESTEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEELCLAD W/ FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ S 100% METHANOL COMPATIBLE W/FRP (PrimaryTank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING C. INTERIOR ❑ 5 GLASS LINING 5;��UNUNED ❑ 95 UNKNOWN99 ❑ OTHER LINING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES _ NO— D. CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER IV. PIPING INFORMATION CIRCLE A IFABOVE NDOR U IF UNDERGROUND, BOTH IF APPLICABLE A. SYSTEM TYPE A hl SUCTION pU 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A 1 SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND A 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 =ZED GALVANIZED STEEL A U W CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION 1 AUTOMAT IC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING O O INTERSTITIAL 9g OTHER MONITORING ❑ V. TANK LEAK DETECTION 1. ❑ 1 ISUAL CHECK 2 INVENTORY RECONCILIATION ❑ 3 VAPOR MONITORING ❑ 4 AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING 6 TANK TESTING ❑ 7 INTERSTITIAL MONITORING ❑ 91 NONE ❑ 95 UNKNOWN ❑ M OTHER VI. TANK CLOSURE INFORMATION 1. ESTIMATED DATE LAST USED (MO/DAY/YR) 2. ESTIMATED QUANTITY OF 3. WAS TANK FILLED WITH SUBSTANCE REMAINING GALLONS INERT MATERIAL? YES ❑ NO ❑ THIS I-UHM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND COR APPLICANTS NAME (PRINTED 8 SIGNATURE) DATE LVVNL HU C14U T UOC VINLT INE 5IAIE I.U. NUMB ER 15 COMPOSED OF THE FOUR NUMBERS B ELOW COUNTY# JURISDICTION# FACILITY# TANK# STATE I.D.# ® I I I I I �1 11 21 PERMIT NUMBER PERM IT APPROVED BY/DATE PERMIT EXPIRATION DATE ECT FORM B (9-90) I rua runm mubI ee AGWMPANILU BY A PLHMII APPLICATION • FORM A, UNLESS A CURRENT FORM A HAS BEEN FILED. FORDOZ14MA