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' STATE OF CALIFORNIA �' STATE WATER RESOURCES CONTROL BOARD W`y UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B ��4FF,..�� ° a Y/� 0 COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. ��1��""� MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION a 7 PERMANENTLY CLOSED ON SITI ONE REM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 6 TANK REMOVED L DBA OR FACILITY NAME WHERE TANK IS INSTALLED: S,670 1-&4 ( A✓A�- ❑ 7 METHANOL ❑ 3 CHEMICAL PRODUCT I TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A. OWNEWS TANK I. D.a 1- B. B. MANUFACTURED BY: -"'7d I. REGULAR C. UNLEADED 3 DIESEL C. DATE INSTALLED(MOADAYHEAR) ❑ ROLEUM �/J`O>/ a/f D. TANK CAPACITY IN GALLONS: � PRODUCT II.TANKCONTENTS IFA -1 IS MARKED. COMPLETE ITEM C. A 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. ❑ 3 SINGLE WALL WITH EXTERIOR LINER I. REGULAR C. UNLEADED 3 DIESEL ❑ 6 AVIATION GAS ❑ ROLEUM ❑ 60 EMPTY ❑ 99 OTHER � PRODUCT ❑ 1 PREMIUM A GASALKIL ❑ 7 METHANOL ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 5 CONCRETE ❑ 2 WASTE UNLEADED ❑ 2 LEADED 5 JET FUEL 99 OTHER (DESCRIBE IN ITEM O. BELOW) D. IF (A.1) IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED tfpC. ❑ 9 BRONZE ❑ 10 GALVANIMD STEEL A S. v: ❑ 99 OTHER III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A. B. AND C. AND ALL THAT APPLIES IN BOX D AND A. TYPE OF SYSTEM TYPE 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM A U 99 OTHER 2 SINGLE WALL ❑ ♦ SECONDARY CONTAINMENT (VAULTEDTANK) ❑ 99 OTHER A®2 DOUBLE WALL A U ❑ 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS A STEEL CLAD W/ FIBERGLASS REINFORCED PLASTIC B. TANK MATERIAL ❑ 5 CONCRETE ❑ 8 POLYVINYL CHLORWE ❑ 7 ALUMINUM ❑ 6 10016 METHANOL COMPATIBLE WIFRP (PrimaryTank) ❑ 9 BRONZE ❑ 10 GALVANIMD STEEL ❑ 95 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED ❑ 2 ALKYD LNWGn 3 EPDXY LINING ❑ A PHENOLIC LINING C. INTERIOR 5 GLASS LINING ❑ 6 UNLINED 95 UNKNOWN ❑ 99 OTHER LINING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO— D. CORROSION ❑ I POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ S CATHODIC PROTECTION ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER E. SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED (YEAR OVERFILL PREVENTION ECUIPMENT 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 6Y2 PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL A®2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U W OTHER C. MATERIAL AND CORROSION PROTECTION A U A U A U 1 BARE STEEL S 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 6 FIBERGLASS PIPE 7 STEEL W/ COATING A U 6 100% METHANOL COMPATIBLE W/FRP A U 95 UNKNOWN A&9 OTHER FOjT' D. LEAK DETECTION ❑ 1 AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTINGMONITORING ❑ 99 OTHER V. TANK LEAK DETECTION ❑ 1 VISUAL CHECK E,.�7,, ))2 INVENTORY RECONCILIATION ❑ 3 VADOZE MONITORING ❑ A AUTOMATIC TANK GAUGING ❑ 5 GROUNDWATER MONITORING ❑ 6 TANK TESTING }/7 INTERSTITIALMOMTORING ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER VI. TANK CLOSURE INFORMATION 1. ESTIMATED DATE LAST USED(MO/DAY/YR) 2. ESTIMATED DUMMY OF 3 WAS TANK FILLED WITH YES ❑ NO❑ SUBSTANCE REMAINING GALLONS I INERTMATERIAL? THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE. IS TRUE AND CORRECT APPLICANT'S NAME DATE IPRI T P 6 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 APPUCATION - FORMA, UNLESS A CURRENT FORMA HAS BEEN FILED. 0 0 FORMBAS COUNTY It JURISDICTION # FACILITY # TANK # � STATE I.D.# 2j� f y l qb PERMITNUMBER PERMIT APPROVED BY/DATE I PERMIT EXPIRATION DATE FORM B (7.91) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPUCATION - FORMA, UNLESS A CURRENT FORMA HAS BEEN FILED. 0 0 FORMBAS