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\ e STATE OF CALIFORNIA v .c STATE WATER RESOURCES CONTROL BOARDLz e UNDERGROUND STORAGE TANK PERMIT APPLICATION • FORM B COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLYNEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY C N ITE ONE ITEM 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT L_j 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED t DBA OR FACILITY NAME WHERE TANK IS INSTALLED: v ID �J�,�/,,GJ�,j(��J I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A. OWNERS TANK I.D.# 2- B. MANUFACTURED BY: x�s C. DATE INSTALLED(MO/DAY/YEAR) Li 8 D. TANK CAPACITY IN GALLONS: 1p 000 IL TANK CONTENTS IFA-11SMARKED,COMPLETE ITEM C. A 1JJ 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C. ❑ 1aREGULAR 3 DIESELUNLEADED 4 GAS ❑ 6 AVIATION GAS !❑ 2 PETROLEUM O W EMPTY 1 PRODUCT ISI 1bUNLEAIDED ❑ 5 JET FUEL ❑ 7 METHANOL ❑ 3 CHEMICALPRODUCT ❑ 96 UNKNOWN 2 WASTE O 2 LEADED O 99 OTHER (DESCRIBE IN ITEM D. BELOW) D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S.R: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A,B,AND C,AND ALL THAT APPLIES IN BOX D AND A. TYPE OF ❑ 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM p 2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER B. TANK ❑ 1 BARE STEEL ❑ 2 STAINLESS STEEL 154 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE a 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE WIFRP (PrimeryTmk) ❑ 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 pp�� 6 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER LINING K 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 a95 UNKNOWN ❑ 99 OTHER E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) tllo IV.PIPING INFORMATION CIRCLE A IFABOVEGROUNDOR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEMTYPE A U 1 SUCTION A02 PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A 9 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 U 1 RARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A dD 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 A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION ❑ 1 AUTOMATIC LINE LEAK DETECTOR W] 2 LINE TIGHTNESS TESTING ❑ 3 INTERSTITIAL MONRORING ❑ OTHER V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK 2 INVENTORY RECONCILIATION ❑ 3 VADOZE MONITORING ❑ 4 AUTOMATIC TANK GA ING ❑ 5 GROUND WATER MONITORING 6 TANK TESTING ❑ 7 INTERSTITIAL MONITORING ❑ 91 NONE ❑ 95 UNKNOWN 99 OTHER SI P_ VI.TANK CLOSURE INFORMATION 1.ESTIMATED DATE LAST USED(MO/DAY/YR) 2.ESTIMATED QUANTITY OF 3.WAS TA LLED WITH SUBSTANCE REMAINING L NS INERTM ❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF P Y,ANDITP T4 B KNOWLEDGE, IS TRUE AND CORRECT APPLICANTS NAMEDATE (PRINTEDA SIGNATURE)T 11 V I Q TO.1-}s, \ � 1-2- - I -7 - g LOCAL AGENCY USE ONLY THE ISTTATEI.I.D.NUMBER IS COMPOSED OF THE FOU NUMBE S BELOW COUNTY# JURISDICTION# FACIL # TANK# 2,/�� STATE I.D.# p diO a PERMITNUMBER i 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 FILED. ROOM9R5 N _J