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STATE OFCAUFORNIA • ° °° s STATE WATER RESOURCES CONTROL BOARD ice' 3 UNDERGROUND STORAGE TANK PERMIT APPLICATION -FORMB "� a Y / � C COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION B. MANUFACTURED BY: i/�� n� ( „ I i 7 PERMANENTLY CLOSED ONSITE ONE REM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 6 TANK REMOVED O DBA OR FACILITY NAME WHERE TANK IS INSTALLED: 5dv f -v _ ��II PRODUCT ❑ 1. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A. OWNER'S TANK 1.0.0f -- JG ❑ 6 OIL B. MANUFACTURED BY: i/�� n� ( „ I i C. DATE INSTALLED(MOIDAYNEAR) d/3 1a REGULAR D. TANK CAPACITY IN GALLONS: 6 truCJ ILTANKCONTENTS IFA-11SMARKED.COMPLETE(TEMC. A MOTOR VEHICLE FUEL ❑ 6 OIL 8. C. ❑ 1a REGULAR ❑ 2 SINGLE WALL DIESEL ❑ 6 AVIATK)N GAS ❑ 2 PETROLEUM ❑ BO EMPTY ��II PRODUCT ❑ UNLEADED lb DUN ELEMIUMADED B. TANK MATERIAL • GASAHOL ❑ 7 METHANOL ❑ 7 ALUMINUM ❑ 9 100% METHANOL COMPATIBLE WIFRP 4N WASTE ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN 5 JETFUEL LEAK DETECTION ❑ 3 CHEMICALPRODUCT ❑ 95 UNKNOWN ❑ ❑ 2 LEADED ❑ 5 GLASS LINING 99 OTHER (DESCRIBE IN ITEM 0. BELOW) D. IF (A.I) IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED LINING C. A. S. v: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A,B. AND C. AND ALL THAT APPLES IN BOX D AND A. TYPE OF r=Kl DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR UNER ❑ 95 UNKNOWN SYSTEM ❑ 2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER B. ❑ 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS 4 STEEL CLAD Wl FIBERGLASS REINFORCED PLASTIC B. TANK MATERIAL ❑ 5 CONCRETE ❑ 8 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 9 100% METHANOL COMPATIBLE WIFRP (PrimaryTank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER LEAK DETECTION ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING 3 EPDXY LINING ❑ 4 PHENOLIC LINING C. INTERIOR ❑ 5 GLASS LINING ❑ 6 UNLINED 95 UNKNOWN ❑ 99 OTHER LINING IS LINING MATERIAL COMPATIBLE WITH 1005: METHANOL? YES_ NO O.CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP "Cu FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE ❑ 95 UNKNOWN = 999 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 Ag2 PRESSURE A U 3 GRAVITY A U N OTHER B. CONSTRUCTION A U 1 SINGLE WALL A U 2 DOUBLE 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 A U A U 2 STAINLESS STEEL A U 6 CONCRETE A U 10 CATHODIC PROTECTION 3 POLYVINYL CHLORIDE (PVC)A U 4 FIBERGLASS PIPE 7 STEEL WICOATING A U IOD% METHANOL COMPATIBLE WIFRP A U 95 UNKNOWN ( 1 99 OTHER D. LEAK DETECTION ❑ 1 AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING fl..Uj MONITORING ❑ 9B OTHER V. TANK LEAK DETECTION I ❑ 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VADOZE MONITORING ❑ 4 AUTOMATIC TANK GAUGING ❑ 5 GROUNDWATER MONITORING ❑ 6 TANK TESTING ❑./I INTERSTITIAL MONITORING I❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER 1. ESTIMATED DATE LAST USED (MOIDAYIYR) I 2. ESTIMATED QUANTITY OF I S. WAS TANK FILLED WITH YES ❑ NO ❑ SUBSTANCE REMAINING GALLONS INERTMATERIAL7 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 a S"A111Rq LOCAL AGENCY USE ONLY THE STATE I.D. NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COm JILLLJ FACT T STATE I.D.# f 6 RERMIT 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 FORMSAS