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0A .6° STATE OF CALIFORM ., tii STATE WATER RESOURCES CONTROL BOARD s a UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B q.�� '� ❑ Yom. 0 COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. °��,�°""" MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT B. MANUFACTURED BY: v 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ON SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 8 TEMPORARY TANK CLOSURE ❑ 9 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN 2 WASTE ❑ 2 LEADED ❑ 9 100% METHANOL COMPATIBLE W/FRP r TA IV mCCP0IOTI/1M ,e .,i _ mcnw¢nu¢unwu A. OWNETS TANK I. D.4 ❑ 4 OIL B. MANUFACTURED BY: v �+ C/•Z C. DATE INSTALLED(MO/DAYYEAR) / Gt '7 D. TANK CAPACITY IN GALLONS: jte R TA kfl/ rnAITCNITC 11. — o11T ITCI11 A MOTOR VEHICLE FUEL ❑ 4 OIL B. C. -u \aREGU FI UNLE❑ —❑ bPREMIUM SYSTEM 3 DIESEL ❑ S AVIATIONGAS 4 GASAHOL ❑ 7 METHANOL 2 PETROLEUM ❑ 80 EMPTY PRODUCT UNLEADED ❑ 2 STAINLESS STEEL 5 JETFUEL ❑ 4 STEEL CLAD W/ FIBERGLASS REINFORCED PLASTIC 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN 2 WASTE ❑ 2 LEADED ❑ 9 100% METHANOL COMPATIBLE W/FRP 99 OTHER (DESCRIBE IN ITEM D. BELOW) D. IF (A.1) IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED ❑ 95 UNKNOWN ❑ 99 OTHER A U C. A. S. 4: ALKYD LINING III TAAIIC r1r1A1CT12IICTVTAI uAovnmCITPUnNIVIMQnYCQA P ANnC ANn All THATAPPIIFSINROXOANOE A. TYPE OF 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM 2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER WALL �I BARE STEEL ❑ 2 STAINLESS STEEL [73 FIBERGLASS ❑ 4 STEEL CLAD W/ FIBERGLASS REINFORCED PLASTIC B. TANK MATERIAL ❑ 5 CONCRETE ❑ 8 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 9 100% METHANOL COMPATIBLE W/FRP (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER A U ❑ 1 RUBBER LINED ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING C. INTERIOR ❑ 5 GLASS LINING UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER LINING AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING ❑ 3 MONITORING [:]99 OTHER IS LINING MATERIAL COMPATIBLE WITH 10D% 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. PIPINr 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 ASINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND A U 1 BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE (PVC) A U 4 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 8 CONCRETE A U 7 STEEL W/COATING A U 8 100% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION AMA UNKNOWN A U 99 OTHER D. LEAK DETECTION ❑1 AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING ❑ 3 MONITORING [:]99 OTHER V. TANK LEAK DETECTION ❑ I VISUAL CHECK�2 INVENTORY RECONCILIATION ❑ 3 VADOZE MONITORING ❑ 4 AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING ❑ 8 TANK TESTNG 7 INTERSTITIAL MONITORING ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER INFORMATION 1. ESTIMATED DATE LAST USED�(1.�0/[�A� 2 SUBSTATED NCE PEOF MAINING _GALLONS 3. WASNERT MATERIALTANK FILLED I?H YES [:]NO ❑ 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 SIGNAMREI LOCAL AGENCY USE ONLY THE STATE I.D. NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY # JURISDICTION # FACILITY # TANK # STATE I.D.# PERMIT NUMBER PERMIT APPROVED BY/DATE 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