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• a SLATE OF CALIFORMA STATE 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 INFORMATION F-7 7 PERMANENTLY CLOSED ONSITE ONE ITEM ❑ 2 INTERIM PERMIT ❑11 d AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 6 TANK REMOVED O DBA OR FACILITY NAME WHERE TANK IS INSTALLED: DO Z o6 A G 2 STAINLESS STEEL ❑ 3 FIBERGLASS I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A. OWNER'S TANK I.D.# K-• :/ B. MANUFACTURED BY: �4D �4 ��] j &,� :::] C. DATE INSTALLED (MO/DAY/YEAR) b D. TANK CAPACITY IN GALLONS: 7 1I. TANK CONTENTS IFA-11SMARKED.COMPLETE ITEM C. A E?�,1_MOTOR VEHICLE FUEL ❑ d OILB. t DOUBLE WALL C.tj 1aUNLEA ED DGASAERLIOL ❑ 6 AVIATION GAS ❑ 2 PETROLEUM ❑ 80 EMPTY PROD CT d Ib PRF IUM ❑ 5 :ET FUEL 1--]7 METHANOL UNL❑ 3 CHEMICALPRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED j❑ 99 OTHER (DESCRIBE IN ITEM 0. BELOW) D. IF (A.1) IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C. A. S. a : III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.S.AND C. AND ALL THAT APPLIES IN BOX D AND A. TYPE OF t DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM ❑ 2 SINGLE WALL ❑ d SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER A U I 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS STEEL CLAD W1 FIBERGLASS REINFORCED PLASTIC B. TANK MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ B 1002 METHANOL COMPATIBLE WIFRP (Primary Tank) ❑ 9 BRONZE LEAK DETECTION 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ W OTHER ❑1 t RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING d PHENOLIC LINING C. INTERIOR j^..I 5 GLASS LINING ❑ 6 UNLINED 95 UNKNOWN HE ❑ 99 OTR LINING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO— D. CORROSION ❑ I POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP FIBERGLASS REINFORCED PLASTIC PROTECTION 5 CATHODIC PROTECTION ❑ 91 NONE [:D 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 I SUCTION A &U-1 PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL A C2 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 d FIBERGLASS PIPE 7 STEELWICOATING A U 6 10Oa. METHANOL COMPATIBLE WIFRP A U 95 UNKNOWN A� OTHER_?i i I /L D. LEAK DETECTION ❑ 1 AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING AIO'To RING L_ 99 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 7 INTERSTITIAL MONITORING ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER VI. TANK CLOSURE INFORMATION 1. ESTIMATED DATE LAST USED (MO/DAY/YR) 2. ESTIMATED QUANTITY OF 3. WAS TANK FILLED WITH YES ❑ NO ❑ SUBSTANCE REMAINING GALLONS INERT MATERIAL? THIS FORM HAS BEEN COMPLETED UNDER PENAL TY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE. IS TRUE AND CORRECT APPLICANTS NAME DATE 1PRINTEO 8 SIGUANRE) LOCAL AGENCY USE ONLY THE STATE I.D. NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW STATE I.D.# COUNTY # JURISDICTION # FACILITY # TANK # 'ERMIT 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 FOROOMILR5