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JYJJwf SS STATE OFCALIFORMA � �' STATE WATER RESOURCES CONTROL BOARD i P'' aL-yi� .' UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B o ��,�.c. COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION j❑ 7 PERMANENTLY CLOSED ONSITE ONE REM ❑ 2 INTERIM PERMIT '❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ a TANK REMOVED ((.J �� DBAOR FACILITY NAME WHERE TANK IS INSTALLED: y579b ey, L -LT / /9 C. MATERIAL AND CORROSION PROTECTION I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A. OWNER'S TANK L0.s /!.�{ I R- MANUFACTURED BY: (!G C. DATE INSTALLED(MOIDAY/YEAR) / g�, D. TANK CAPACITY W GALLONS: Y II. TANK CONTENTS IFA -1 IS MARKED. COMPLETE ITEM C. A 1 MOTOR VEHICLE FUEL 4 OIL B. C. REGULAR taUNLEADED 8 3 DIESEL ❑ 6 AVIATIONGAS ❑ 2 PETROLEUM ❑ W EMPTY I., PRODUCT ❑ lb PREMIUM B. TANK 4 GASAHOL ❑ ] METHANOL C. MATERIAL AND CORROSION PROTECTION MATERIAL ❑ 5 CONCRETE UNLEADED ❑ 5 J (Primary Tank) ❑I 3 CHEMICALPRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED ❑ OT W O OTHER(DESCRIBE IN ITEM D. BELOW) D. IF (A1) IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED ❑ 4 PHENOLIC LINING C. INTERIOR ❑ 5 GLASS LINING6 C. A S.9: F795 UNKNOWN III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A,S.AND C. AND ALL THAT APPLIES IN BOX D AND A. TYPE OF F7 1 DOUBLE WALL 7 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM EN 2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT IVAULTED TANK) ❑ 99 OTHER B. ttli,BARE STEEL F72 STAINLESS STEEL F-]3 FIBERGLASS ❑ 4 STEEL CLAD W/ FIBERGLASS REINFORCED PLASTIC B. TANK 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND CORROSION PROTECTION MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ ] ALUMINUM ❑ B 100% METHANOL COMPATIBLE W/FRP (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER MONITORING ❑ 1 RUBBER LINED ❑ 2 ALKYD LNING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING C. INTERIOR ❑ 5 GLASS LINING6 UNLINED F795 UNKNOWN ❑ 99 OTHER LINING IS LINING MATERIAL COMPATIBLE WITH I0 METHANOL? YES_ NO_ D.CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC 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 IFABOVEGROUNOOR U IFUNDERGROUNO. MOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION A 2 RESSURE 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 CORROSION PROTECTION A U A U A U I 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 IPVC) A U 7 ST�W/COATING A U p U UNKNOWN A U 4 FIBERGLASS PIPE 6 100% METHANOL COMPATIBLE W/FRP 99 OTHER D. LEAK DETECTION ❑ I AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING ❑ I MONITORING E] 99 OTHER V. TANK LEAK DETECTION 7-1 1 VISUAL CHECK 2 INVENTORY RECONCILIATION ❑ 3 VADOZE MONITORING ❑ 4 AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING 6 TANK TESTING a 7 INTERSTITIAL MONITORING ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER i. ESTIMATED DATE LASTUSED,(ALO/DAY 2. SUBSTANCE REMAININGF %� GALLONS 3 WASTANK FILLED NERT MATERIALI7H YES ❑ 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 A SIGNATUAEI LOCAL AGENCY USE ONLY THE STATE I.D. NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW STATE I. Dl COUNTY # m%6 JURISDICTION # FACILITY # TANK # PERMIT NUMBER PERMIT APPROVED BYIDATE 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 F0R93MB-R5