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• STATE OF CALIFORNIA • �'� STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B .r , 1 1 ' COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ❑1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION El7 PERMANENTLY CLOS ON SIT[ ONE REM F-1 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED / DBA OR FACILITY NAME WHERE TANK IS INSTALLED: 2*✓ Al' A011 - TA IV ✓r TAUV MtQP010Tnld. __..-..__.. _..._ _. ___ coFCIFYIFIINKNOWN A OWNER'S TANK I D N 2 B. MANUFACTURED BY: C DATE INSTALLED (MO/MAYNEAR) /,97 % / D. TANK CAPACITY IN GALLONS: Q, 4)(Z II TAUV P/1MTCMTC IC A 1 is IAAM Cn rnM01 FTF ITEM C. 1 MOTOR VEHICLE FUEL ❑ d OIL B. � C. 1A REGULAR UNLEADED ❑ 3 DIESEL ❑ 8 AVIATION GAS A ❑ 2 PETROLEUM ❑ BO EMPTY Lam! PRODUCT 1G PREMIUM UNLEADED ❑ E]4 GASAHOL ❑ 7 METHANOL ❑ tG MIDGflADE UNLEADED ❑ 5 JET FUEL ❑ 8 M85 ❑ 3 CHEMICALPRODUCT ❑ 95 UNKNOWN [-]2 WASTE ❑ 2 LEADED ❑ 99 OTHER (DESCRIBE IN ITEM D. BELOW) D. IF (A.1) IS NOT MARKED, ENTER NAME OFSUBSTANCE STORED C. A. S. M: III TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.3, AND C, AND ALL THAT APPLIES IN BOX D ANDS ❑T 1 DOUBLE WALL - __ ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 5 INTERNAL BUDDER SYSTEM ❑ 95 UNKNOWN A. TYPE OF SYSTEM I� 2 SINGLE WALL F74 SINGLE WALL IN A VAULT ❑ 99 OTHER A U t!J`t BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/ FIBERGLASS REINFORCED PLASTIC B. TANK MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 6 100% METHANOL COMPATIBLE W/FRP (Prlmery Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER 1 BARE STEEL 5 ALUMINUM 9 GALVANIZED STEEL ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING C. INTERIOR LINING OR ❑ 5 GLASS LINING 6 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 1001A METHANOL? YES_ NO— D. EXTERIOR ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC CORROSIONF�95 ❑ 5 CATHODIC PROTECTION ❑ 91 NONE L,LJ UNKNOWN ❑ 99 OTHER PROTECTION SPILL CONTAINMENT E SPILL AND OVERFILL, BIC. INSTALLED (YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) O_ NO_ STRIKER PLATE VES_ NO_ DISPENSER CONTAINMENT YES_ NO- DROPTUBE YES_ ....__ II -...mem—noun nnTM l[ ARM ICARIF I TAUV I CAV nCTCPTIPM r. rnnrx I_-%— ANNUAL F-1 1 VISUAL CHECK 2 MANUAL INVENTORY ❑ 3 ❑ 4 GAUGING AUTOMATIC TANK ❑ 5 GROUND MONITORINGTER ❑ 6 TESTING RECONCILIATION MONITORING MONITORING ❑ 7 MONITORING INTERSTITIAL 8 SIR ❑ 9 WANK GAUGINGAL ❑. MONTHLY TANK ❑ 95 UNKNOWN ❑ 99 OTHER VI. TANK CLOSURE INFORMATION (PERMANENT CLOSURE IN -PUCE) 1. ESTIMATED DATE LAST USED (MO/DAVA'R) 2. ESTIMATED QUANTITY OF 3. WAS TANK FILLED WITH YES E:] NO E]SUBSTANCE REMAINING GALLONS INERT MATERIAL? THI,"Alrl= PPAIAI ry rIF PFR II IRY AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT DATE TANK OWNER'S NAME (PRINTED 4 SIGNANRE) LOCAL AGENCY USE ONLY THE STATE I.D. NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY # JURISDICTION # �FACILITY # �-�--� TA�NK--#-� STATE I.D.# � = I I I L_L_JTTE-J PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION- FORM A. UNLESS A DUHKLN I tUKMA HAa eern IILCV. r..n,..�...,,.,..,......... ...-....... •..-••.-_.-..-.-. __-- SHOULD BE ACCOMPANIED BY A PLOT PLOE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE IfGROUND STORAGE TANK REGULATIONS FOfl0G3/&AI FORM B (6.95) A. SYSTEM TYPE A U 1 SUCTION Uj 2 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLEPIPING A U 99 OTHER B. CONSTRUCTION A 1 SINGLE WALL A U 2DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND CORROSION PROTECTION A U A U A U 1 BARE STEEL 5 ALUMINUM 9 GALVANIZED STEEL A U 2 STAINLESS STEEL A U A U 6 CONCRETE A U A U 10 CATHODIC PROTECTION 3 POLYVINYL CHLORIDE (PVC)A U 4 FIBERGLASS PIPE 7 STTESELL W/COATING A U 8 100% METHANOL COMPATIBLE W/FRP P4 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION ❑ 1 MEC1+011 l UNE LEAK M7EMOR ❑ 2 UNE TGWNDM 3 CONTNIIWS RRERSTIINL ❑ 4 ELECTRONIC LINE ❑ TESTING ❑ MGMTmNG LEAK DETECTOR 5 AUfONATIC PUMP ❑ 99 OTHER EHUTOOWN I TAUV I CAV nCTCPTIPM r. rnnrx I_-%— ANNUAL F-1 1 VISUAL CHECK 2 MANUAL INVENTORY ❑ 3 ❑ 4 GAUGING AUTOMATIC TANK ❑ 5 GROUND MONITORINGTER ❑ 6 TESTING RECONCILIATION MONITORING MONITORING ❑ 7 MONITORING INTERSTITIAL 8 SIR ❑ 9 WANK GAUGINGAL ❑. MONTHLY TANK ❑ 95 UNKNOWN ❑ 99 OTHER VI. TANK CLOSURE INFORMATION (PERMANENT CLOSURE IN -PUCE) 1. ESTIMATED DATE LAST USED (MO/DAVA'R) 2. ESTIMATED QUANTITY OF 3. WAS TANK FILLED WITH YES E:] NO E]SUBSTANCE REMAINING GALLONS INERT MATERIAL? THI,"Alrl= PPAIAI ry rIF PFR II IRY AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT DATE TANK OWNER'S NAME (PRINTED 4 SIGNANRE) LOCAL AGENCY USE ONLY THE STATE I.D. NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY # JURISDICTION # �FACILITY # �-�--� TA�NK--#-� STATE I.D.# � = I I I L_L_JTTE-J PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION- FORM A. UNLESS A DUHKLN I tUKMA HAa eern IILCV. r..n,..�...,,.,..,......... ...-....... •..-••.-_.-..-.-. __-- SHOULD BE ACCOMPANIED BY A PLOT PLOE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE IfGROUND STORAGE TANK REGULATIONS FOfl0G3/&AI FORM B (6.95)