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• • oua STATE OF CALIFORNIA G °+, STATE WATER RESOURCES CONTROL BOARD i UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B W ��° r COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. c�`��°°�� MARK ONLY 1 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 DBA OR FACILITY NAME WHERE TANK IS INSTALLED: So7,0 11_ i;Aa >` D A fti ro Gc>v ❑ 3 CHEMICALPRODUCT ❑ 95 UNKNOWN ® 2 WASTE I. TANK DESCRIPTION COMPLETE ALL ITEMS-- SPECIFY IF UNKNOWN A. OWNER'S TANK I.D.# © 4 OIL O B. MANUFACTURED BY: Pdc C. ❑ 1aR ULAR G L ❑ 2 PETROLEUM C. DATE INSTALLED (MO/DAY/YEAR) /� - PRODUCT D. TANK CAPACITY IN GALLONS: CSD ❑ 3 CHEMICALPRODUCT ❑ 95 UNKNOWN II.TAMKCONTENTS IFA -11S MARKED. COMPLETE ITEM C. A ❑ 1 MOTOR VEHICLE FUEL © 4 OIL B. ❑ 95 UNKNOWN C. ❑ 1aR ULAR ❑ 3 DIESEL ❑ 6 AVIATIONGAS ❑ 2 PETROLEUM ❑ 00 EMPTY ❑ 1 PRODUCT ❑ 1bUNL OL JET FUEL ❑ 7 METHANOL ❑ 3 CHEMICALPRODUCT ❑ 95 UNKNOWN ® 2 WASTE AID D ❑ 2 LADED ❑ 5 ❑ 99 OTHER (DESCRIBE IN ITEM D. BELOW) D. IF (A.1) IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED Wow s i 0i L ❑ 99 OTHER 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 ® 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM ❑ 2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER B. ❑ 1 BARE STEEL ❑ 2 STAINLESS STEEL E)3 FIBERGLASS 4 STEEL CLAD W/ FIBERGLASS REINFORCED PLASTIC B. TANK MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 9 100% METHANOL COMPATIBLE W/FRP (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER 4 FIBERGLASS PIPE ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING C. INTERIOR ❑ 5 GLASS LINING X 6 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER LINING CORROSION A U 5 ALUMINUM A U 6 CONCRETE A07 IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO_ 8 100% METHANOL COMPATIBLE W/FRP D.CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑K 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONEq ❑ 95 UNKNOWN ❑ 99 OTHER �. E. SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED (YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) s IV. PIPING INFORMATION CIRCLE A IFABOVEGROUNDOR U IF UNDERGROUND. BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A g3 GRAVITY A U 99 OTHER B. CONSTRUCTION A(y 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 A07 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 DETECTIO AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING ❑ 0 IIT ERSTITAL MONITORING ❑ 99 OTHER V. TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VADOZE MONITORING ❑ 4 AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING ❑ 6 TANK TESTING ® 7 INTERSTITIAL MONITORING ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER VI. TANK CLOSURE INFORMATION 1. ESTIMATED DATE LAST U ED (MO/DAY/VR) 2. ESTIMATED QUANTITY OF 3. WAS TANK FILLED WITH YESNO SUBSTANCE REMAINING GALLONS INERT MATERIAL? ❑ ❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANPS NAME DATE I6gINTEDdSIGNAjNRE) /� n ^�.2S n( 6S nl/AF A/,),,L n.,A4 L A.✓V 0 //.0/ ./ /i//A, ,/ O 7J LOCAL AGENCY USE ONLY THE STATE I.D. NffMBER IS COMPOSED OF THE FOUR NUMBERS BELOW FORM B (7-91) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION - FORM A, UNLESS A CURRENT FORM A HAS BEEN FILED. 0 0 F0R0070&R5 COUNTY# JURISDICTION# FACILITY# TANK# Q STATE I.D.# m 0 0 91111.2 PERMIT NUMBER 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. 0 0 F0R0070&R5