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a STATE OF CALIFORNIASTATE WATER RESOURCES CONTROL BOARDUNDERGROUND 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 INFORMATICW 7 PERMANENTLY CLOSED ONSITE ONE REM ❑ 2 INTERIM PERMIT ❑ d AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: 7'6�op /,OQ / ✓f I. TANK DE'bUNI1' I IUN COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A. OWNERS TANK I. 0.a B. MANUFACTURED BV: C. DATE INSTALLED(MO/DAVNEAR) 1� `�� 0. TANK CAPACITY IN GALLONS: II TANK(`TTNTFNTC IP e_. IRueoYFn m.PI FTFITFuc 1 MOTOR VEHICLE FUEL � 4 OIL B. L. I REGULAR F 13 DIESEL ❑ 6 AVIATION GAS A CONSTRUCTION ppp��, 5 1 PRODUCT 2 STAINLESS STEEL UNLEADED 1b PREMIUM I`L-J{ d GASAHOL ❑ 7 METHANOL O 2 PETROLEUM ❑ 80 EMPTY —\ ❑ UNLEADED 5 JE7 FUEL ❑ 10 GALVANIZED STEEL ❑ 3 CHEMICALPRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED 1 99 OTHER (DESCRIBE IN ITEM D. BELOW) D. IF (A.1) IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED F75 GLASS LINING ❑ 6 UNLINED C. A. S. s: ❑ N OTHER III TANK C(TNRTRIICTITTN UAQWMF=UONI YIN QnYFS d F AM1C ANn A11 THAT APPI IFR IN ROYn ANnF A. TYPE OF 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM 2 SINGLE WALL ❑ d SECONDARY CONTAINMENT (VAULTED TANK)��❑,,//��99 OTHER CONSTRUCTION ❑ 1 BARE STEEL 2 STAINLESS STEEL n 3 FIBERGLASS d STEEL CLAD W7 FIBERGLASS REINFORCED PLASTIC B. TANK MATERIAL ❑ 5 CONCRETE 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM 9 100K METHANOL COMPATIBLE W/FRP (PrimaryTank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER LEAK DETECTION ❑ 1 RUBBER LINED ❑ ? ALKYD LINNG 17 3 EPDXY LINING F7 PHENOLIC LINING C. INTERIOR F75 GLASS LINING ❑ 6 UNLINED �f/95 UNKNOWN ❑ N OTHER LINING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL 7 F7" ES _ NO_ D. CORROSION 711 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ��, ppp FIBERGLASS REINFORCED PLASTIC PROTECTION E:]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 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 A FIBERGLASS PIPE 7 STEEL W/COATING AU 100% METHANOL COMPA`TIBLE W/FRP A U 95 UNKNO A99 OTHER Obi e - D. LEAK DETECTION ❑ 1 AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING Ef MONITORING ❑i W OTHER V. TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VADOZE MONITORING ❑ d AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING ❑ 6 TANK TESTING I?r7 INTERSTRIALMONITORING ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER 1. ESTIMATED DATE LAST USED (MOIDAY/YR) 2 ESTIMATED QUANTITY OF 3. WAS TANK FILLED WITH YES ❑ NO ❑ 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 APPLICANTS NAME DATE (PRINTED a SIGNATURE) LOCAL AGENCY USE ONLY THE STATE LD. NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW FORMS (7-91) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION • FORM A, UNLESS A CURRENT FORM A HAS BEEN FILED. 0 0 FOROOM&RS COUNTY n JURISDICTION x FACILITY P TANK n STATE I.D.# m L�-7 z2uiyKR 9 Jb� PERMIT NUMBER PERMIT APPROVED BYIDATE I PERMIT EXPIRATION DATE FORMS (7-91) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION • FORM A, UNLESS A CURRENT FORM A HAS BEEN FILED. 0 0 FOROOM&RS