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NUN", lSgUnCGs $TATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY I NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED ON SITE ONE ITEM 2 INTERIM PERMIT 4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE 8 TANK REMOVED DEA OR FACILITY NAME WHERE TANK IS INSTALLED: j 1 fmc—o T"C K �L Z I. TANK DESCRIPTION COMPLETE ALL ITEMS-- SPECIFY IF UNKNOWN A OWNER'S TANK I.D.# l B. MANUFACTURED BY: VA/K-,/pl,�/h1 C. DATE INSTALLED(MOIDAYNEAR) /'j V_A o" D. TANK CAPACITY IN GALLONS', -7` SQA 11.TANK CONTENTS IF A-1 IS MARKED,COMPLETE ITEM C. A � 1 MOTOR VEHICLE FUEL 4 OIL B. 0 ❑ is REGULAR UNLEADED 3 DIESEL ❑ 6 AVIATION GAS F72 PETROLEUM 80 EMPTY 1 PRODUCT ❑ 1b PREMIUM UNLEADED [_] 4 GASAHOL ❑ 7 METHANOL 1c MIOGRADE UNLEADED F-] 5 JET FUEL � 8 M55 3 CHEMICAL PRODUCT 95 UNKNOWN 2 WASTE 2 LEADED E:1 99 OTHER(DESCRIBE IN ITEM D.BELOM D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S.tl' 111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A,B,AND C AND ALL THAT APPLIES IN BOX D AND E A. TYPE OF }❑ 1 DOUBLE WALL 3 SINGLE WALL WITH EXTERIOR LINER ❑ 5 INTERNAL BLADDER SYSTEM ❑ 95 UNKNOWN SYSTEM 2 SINGLE WALL ❑ 4 SINGLE WALL IN A VAULT a 99 OTHER B. TANK 1 BARE STEEL 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL 5 CONCRETE 6 POLYVINYL CHLORIDE E] 7 ALUMINUM ❑ H 100% METHANOL COMPATIBLE W1FRP (Primary Tank) ❑ 9 BRONZE 10 GALVANIZED STEEL 95 UNKNOWN 99 OTHER C.INTERIOR ❑ 1 RUBBER LINED 2 ALKYD LINING 3 EPDXY LINING 4 PHENOLIC LINING LINING OR F] 5 GLASS LINING 6 UNLINED ❑ 95 NKNOWN 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES NO_ D.EXTERIOR 1 POLYETHYLENE WRAP 2 COATING VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC CORROSION PROTECTION ❑ 5 CATHODIC PROTECTION a 91 NONE eD ��91 UNKNOWN ❑ 99 OTHER E.SPILL AND OVERFILL,etc. SPILL CONTAINMENT I ALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) Lj Cm) DROP TUBE YES NO STRIKER PLATE YESy NO DISPENSER CONTAINMENT YES NO N. PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND,BOTH TF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION A 2 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING 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 1001/6 METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER MECHANICAL LINE LEAN 2 LINE TIGHTNESS 3 CONTINUOUS INTERSTITIAL 4 ELECTRONIC LINE 5 AUTOMATIC PUMP 99 OTHER D. LEAK DETECTION jllfDETECTOR ❑ TESTING MONITORING ❑ LEAK DETECTOR SHUTI)M" El V.TANK LEAK DETECTION El 1 VISUAL CHECK ❑ 2 MANUAL RECONCILIATION MONITORING 3 MAO ORING 4 AUTOMATGAUGING MONITORING TANK O 5 GROUND MONITORINGTER 6' TETANK STING 7 CONTINUMONITOR U INTERSTITIAL 8 SIR ❑ 9 WEEKLY MANUAL O 10 STINGY TANK 95 UNKNOWN 99 OTHER TANV1.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) 1.ESTIMATED DATE LAST USED(MOiDAYNR) J� 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH Y J" A- SUBSTANCE REMAINING GALLONS INERT MATERIAL? THIS FORM HAS BEEN COMPLETED UNDER P LTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT TANK OWNER'S NAME DATE//�� (PPINTEoa SIGNATURE) M(K67 t- LL( t q N�rj LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW (J' T V COUNTY# JURISDICTION# FACILITY 4 TANK# STATE I.D.# PERMIT NUMBER PERMIT APPROVED BY/DATE PE=RMIT EXPIRATION DATE THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. FORM C MUST BE COMPLETED FOR INSTALLATIONS. THIS FORM SHOULD BE ACCOMPANIED BY A PLOT PLAN. FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS FORM B (6-95)