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STATE OFCAUFORHA '• "_� s- STATE WATER RESOURCES CONTROL BOARD s� UNDERGROUND STORAGE TANK PERMIT APPLICATION• FORM B "� ' COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION RMANENTLY 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: /0�r-v' . G��Pti ci- I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A OWNER'S TANK I.D.6 0 f' B. MANUFACTURED BY: C. DATE INSTALLED(MOIDAY/YEAR) N lc— D. TANK CAPACITY IN GALLONS: ILTANKCONTENTS IFA-11SMARKED,COMPLETE ITEM C. A. ❑ 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C. ❑ la REGULAR e 3 DIESEL ❑ 6 AVIATION GAS TFU PETROLEUM ❑ 80 EMPTY 1 PROOLICT ❑ 10 PREMUNLEA IUM 4 GAS L ❑ 7 METHANOL 3 CHEMICALPROOUCT ❑ 05 UNKNOWN ❑ 2 WASTE ❑ 2 LEADEDD 99 OTHERL(OESCRIBE IN ITEM D. BELOW) D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C. A GLS C.A.S.6: 111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.S.AND C.AND ALL THAT APPLIES IN BOX D AND A. TYPE OF ❑ BLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM 2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER S. TANK ❑ RE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL 6 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ B 100% METHANOL COMPATIBLE W/FRP (PrimMyTW) ❑ 0 BRONZE ❑ 10 GALVANIZED STEEL ❑ 96 UNKNOWN ❑ 90 OTHER ❑ 1 RUBBER LINED ❑ 2 D LINING ❑ 3 EPDXY LINING 4 PHENOLIC LINING C.INTERIOR ❑ 5 GLASS LINING 6 UNLINED ❑ 96 UNKNOWN 09 OTHER 19 LINING MATERIAL COMPATIBLE WITH 100%METHANOL? YES_ NO D.CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 TING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 6 CATHODIC PROTECTION 91 NONE ❑95 UNKNOWN ❑ 90 OTHER E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND,BOTH IFAPPLICABLE A. SYSTEM TYPE A U I SUCTION A U 2 PRESSURE A3 GRAM A U W OTHER B. CONSTRUCTION A U 1 SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U THE 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 STEELW/COATINGA U 6 100% METHANOL MPA I�-j U LEWfFRP A.— PROTECTION A U B GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U �J D. LEAK DETECTION ❑ 1 AUTOMATIC LINE LEAKDETECTOR ❑ 2 LINE TIGHTNESS TESTING ❑ MONOOR IIG ❑ PJ U - V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 V MONITORING ❑ 4 AUTOMATIC TANK GAUGING [:] 5 GROUND WATER MONITORING (J a TANK TESTING ❑ 7 INTERSTITIAL MONITORING 9f NONE ❑ 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION 1.ESTIMATED DATE LAST USED(MO/DAY/YR) 2.ESTIMAD QUANTITY OF 3.WAS TANK FILLED WITH YES NO rL SUB STANTECE REMAINING GALLONS INERTMATERIAL? IJ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANTS NAME DATE IPNNtE9A SXiNAN M LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY A JURISDICTK)N 1n 'FACILITY 1 TANK s �I AAtJ(U STATE I.D.# ® 1 .�.L 41 LZI � PERMITNUMSER PERMIT APPROVED BYIOATE PERMIT EXP�ATIONDATAi3 (, FORM B (7-91) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORM A HASS BEEN FILED. ..ff /// FOROma&0.5