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L 0 STATE OF CALIFORMA STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION /"L- T PERMANENTLY CLOSED ONSITE ONE ITEM ❑ 2 INTERN PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 6 TANK REMOVED 1^� DBA OR FACILITY NAME WHERE TANK IS INSTALLED: " j©p I; Z"�j I A' -e ❑ ] ALUMINUM ❑ B 190% METHANOL COMPATIBLE W/FRP I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A OWNER'S TANK I.D.# d 8. PRODUCT ❑ 2 WASTE B. MANUFACTURED BY: e.-_ /"L- C. DATE INSTALLED(MOrDAYNEAR) C. ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) / �. 7'I D. TANK CAPACITY IN GALLONS: yy je— It TANII/rfTNTGNTC IF s_ne... / nnnuPl FTF MPU r. A MOTOR VEHICLE FUEL ❑ 2 PETROLEUM ❑ 3 CHEMICAL PRODUCT ❑ 4 OIL ❑ 60 EMPTY Q 95 UNKNOWN 8. PRODUCT ❑ 2 WASTE �yy�q to REGULAR C. fIC UNLEADED —❑ `SUNLEADED ❑ 2 LEADED �1 3 DIESEL 6 AVIATION GAS u A GASNOL ❑ ❑ 5 JET FUEL ❑ T METHANOL tfJ^ N OTHER (DESCRIBE IN ITEM 0. BELOW) D. IF (A.1) IS NOT MARKED. ENTER NAME OF SUBSTANCE STORED ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER CONSTRUCTION C. A. S. A : ❑ 2 STAINLESS STEEL III TAMC rn NCTGIICTInN UAnVflMC=UnWf V tNA(IYFSA A GNDC ANn All TWATAPPI IFRINROXDANnF A. TYPE OF 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER 95 UNKNOWN SYSTEM Ri� 2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER CONSTRUCTION I` -'N t BARE STEEL �� ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/ FIBERGLASS REINFORCED PLASTIC B. TANK MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ ] ALUMINUM ❑ B 190% METHANOL COMPATIBLE W/FRP (Primary Tank) 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER A U 1 RUBBER LINED 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING C. INTERIOR —1 5 GLASS LINING LJ UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER LINING AAC5� UNKNOWN A U 99 OTHER D. LEAK DETECTION IS LINING MATERIA COMPATIBLE WITH 100% METHANOL? YES _ NO— MONITORING ❑ 99 OTHER ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC D. CORROSION PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE 95 UNKNOWN 99 OTHER E. SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED (YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED (YEAR) IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND, BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION A '/'PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A 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 (PVL)A U 4 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U T STEEL W/ COATING A U 6 100% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION AAC5� UNKNOWN A U 99 OTHER D. LEAK DETECTION ❑ 1 AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING ❑ 3 MONITORING ❑ 99 OTHER V. TANK LEAK DETECTION ❑ 1 VISUAL CHECK I_ x 2 INVENTORY RECONCILIATION 3 VADOZE MONITORING ❑ 4 AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING ❑ 6 TANK TESTNG ,Tu7 INTERSTITIAL MONITORING ❑ 91 NONE E]95 UNKNOWN ❑ 99 OTHER VI. TANK CLOSURE INFORMATION 1. ESTIMATED DATE LAS±BE Y I 2. SUBSTANCE REMA ESTIMATED NGF _GALLONS I 9. WA INERT MATERIALIOS TANK FILLED ?N YES E:]NO ❑ THIS FORM HAS BEEN/COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANT'S NAME DATE (PRINTED & SIGNATURE( LOCAL AGENCY USE ONLY THE STATE I.D. NUMBER 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 FORMS415 COUNTY # JURISDICTION # FACILITY # TANK # GcT STATE I.D.# PERMIT NUMBER PERMIT APPROVED BYIDATE 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 FORMS415