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0Va Py STATE OF CALIFORNIA �.t ��`� STATE WATER RESOURCES CONTROL BOARD w� ,c %v UNDERGROUND STORAGE TANK PERMIT APPLICATION • FORM B >n ,, nj �n COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. `a,�o"r.� MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATK)N ❑ 7 PERMANENTLY CLOS ON S ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE [j;--B-TANK REMOVED 0 DBA OR FACILITY NAME WHERE TANK IS INSTALLED: I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A. OWNER'S TANK I.D.# B. MANUFACTURED BY: �i e C. DATE INSTALLED(MO/DAY/YEAR) D. TANK CAPACITY IN GALLONS: t O Oa II.TANK CONTENTS IFA-i IS MARKED,COMPLETE ITEM C.A �TTdOTOR VEHICLE FUEL ❑ 4 OIL B. C. ❑q.-1ra.UN EAD R 4 DIESELGASAHL u 6 AVIATION GAS ❑ 2 PETROLEUM ❑ 80 EMPTY TPRODUCT I—I "UPREN EAIUM ❑ 5 JETFUEL ❑ 7 METHANOL ❑ 3 CHEMICALPRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED ❑ 99 OTHER (OESCRIBE IN ITEM D. BELOW) 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 A. TYPE OF �❑ I DOUBLE WALL F-13 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM I=I a SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VA DTANK) ❑ 99 OTHER B. TANK BARE STEEL ❑ 2 STAINLESS STEEL FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL 11T5-CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP (PrimaryTank) ❑ B 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 ❑ 6 UNLINED UNKNOWN ❑ 99 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 Rr�UNKNOWN ❑ 99 OTHER E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR)T OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) u, IV.PIPING INFORMATION CIRCLE AIFABOVEGROUNDORUIFUNDERGROUND,BOTH IFAPPLICABLE A. SYSTEM TYPE1I 1 SUCTION A U 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 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 A(Om UNKNOWN A U 99 OTHER D. LEAK DETECTION [9-rAUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING ❑ 099 OTHER MONRORING ❑ V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VADOZE MONITORING ❑ 4 AUTOMATIC TANK GAUGING ❑ 5 GROUNDWATER MONITORING 5;�r-TANK TESTING ❑ 7 INTERSTITIALMONITORING ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION 1.ESTIMATE ATE LA T USED O/DAY/YR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH SUBSTANCE REMAINING �j('] GALLONS INERT MATERIAL 7 YES L_] NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANTS NAME _ DATE IPRINTED451GNANR �f']_ �+�, G LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW STATE LD.# COUNTY# JURISDICTION# FACILITY# TANK# � �/ PERMIT NUMBER RMIT APPROVED BY/DATE PERMIT EXPIRATION DATE FORM B (7-91) THIS FORM MUST BE ACCOMP IED BY A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. ' FOROrod R5 % v � !/ 7/j!\l i