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_ eeoue p STATE OF CALIFORMA " s� STATE WATER RESOURCES CONTROL BOARD s' ° UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B �� Cl COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. o c""°""�r MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT lfol6CHANGE OF INFORMATION O 7 PERMANENTLY CLOSED ON SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT, ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: — 1 e f O CO I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A. OWNER'S TANK I.D.a O Ur -, Q 2 B. MANUFACTURED BY: C. DATE INSTALLED(MOIDAY/YEAR) '5 0. TANK CAPACITY IN GALLONS: DOV G ILTANKCONTENTS IFA-1 IS MARKED,COMPLETE ITEM C. A. 1 MOTOR VEHICLE FUEL 4 OIL B. C. la REGULAR 3 DIESEL ❑ 6 AVIATIONGAS F—] 2 PETROLEUM ❑ 80 EMPTY PRODUCT 1b PREMIUM 4 GASAHOL 7 METHANOL UNLEADED 5 JET FUEL ❑ 3 CHEMICAL PRODUCT 95 UNKNOWN 2 WASTE ❑ 2 LEADED 99 OTHER (DESCRIBE IN ITEM D. BELO" D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S.a: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.B.AND C,AND ALL THAT APPLIES IN BOX A. TYPE OF �❑ 11 DOUBLE WALL El SINGLE WALL WITH EXTERIOR LINER 95 UNKNOWN 21 SYSTEM I[ye2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTEDTANK) ❑ 99 OTHER B. TANK L�J ' BARE STEEL F7 2 STAINLESS STEEL 3 FIBERGLASS O 4 STEEL CUD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ S POLYVINYL CHLORIDE 7 ALUMINUM 8 100% METHANOL COMPATIBLE W/FRP (PUmuyTmk) ❑ 9 BRONZE O 10 GALVANIZED STEEL 96 UNKNOWN O 09 OTHER ❑ 1 RUBBER LINED 2 ALKYD LINING 3 EPDXY LINING ❑ 4 PHENOLIC LINING C.INTERIOR ❑ 5 GLASS LINING 6 UNLINED F96 UNKNOWN ❑ 99 OTHER LINING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? VES_ NO— D.CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING O 3 VINYL WRAP O 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION O 91 NONE UNKNOWN O 99 OTHER IV.PIPING INFORMATION CIRCLE A IFABOVEGROUNDOR U IF UNDERGROUND,BOTH IFAPPLICABLE A. SYSTEM TYPE A Q> SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A U / SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A&A5UNKNOWN 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 A U 9 GALVANIZED STEEL A U 10 CATHOOICPROTECTION A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION ❑ 1 AUTOMATIC LINE LEAK DETECTOR LINE TIGHTNESS TESTING ❑ J INTERSTITIAL 99 OTHER MONITORING ❑ V.TANK LEAK DETECTION [;�ITANK SUAL CHECK ❑ 2 INVENTORY RECONCILIATION 3 VAPOR MONITORING O 4 AUTOMATIC TANK GAUGING a 5 GROUND WATER MONITORING TESTING ❑ 7 INTERSTITIAL MONITORING ❑ 91 NONE ❑ 95 UNKNOWN O 99 OTHER VI.TANK CLOSURE INFORMATION 1.ESTIMATED DATE LAST USED(MO/DAYNR) 2.ESTIMATED OUANTITY OF 3.WASTANK FILLED WITH YES NO � SUBSTANCE REMAINING GALLONS IN MATERIAL? THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT (PAPPLICANTS NAME DATE RINTED 6 SIGNANRE) LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY# TANK# MAA/;r STATE LDAg 9 p S O U s O d 0 M PERMITNUMBER PERMIT APPROVED BYIDATE PERMIT—EXPIRATION DATE 6 -n FORM B (9-90) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED.. FOROm/BIM _l