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• wa=ea STATE OF CALIFORNIA FORNIA � `; STATE WATER RESOURCES CONTROL BOARD u a,� e UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B >a - , a 1 COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED 0 ]$IT[ ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ B TANK REMOVED e / DBA OR FACILITY NAME WHERE TANK IS INSTALLED: ZSpv °Y' LP,6. AV -6 1 TAMV nCCr`DIDTIfIN CnuPI FTP All ITPMA_ SPECIFY IF UNKNOWN 1. 1..1.1. ......�.... .._.. __.... __.__._ _. _. _ A OWNER'S TANK I D # � S. MANUFACTURED BY: G �/ C DATE INSTALLED (MO/DAYIYEAR) �97 I D. TANK CAPACITY IN GALLONS: /�� V%r, II TANK IF A-1 IS MARKED COMPLETE ITEM C. v111 X1.1.. MOTOR VEHICLE FUEL ❑ 4 OIL B. C to REGUWi UNLEADED ❑ 3 DIESEL ❑ 6 AVIATION GAS A. �1 I-2 SINGLE WALL ❑❑ U PREMIUM UNLEADED O d GASAHOL O 7 METHANOL ❑ 2 PETROLEUM ❑ BO EMPTY 1 PRODUCT tC MIDGRADE UNLEADED 5 JETFUEL 8 M85 ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ p LEADED ❑ 99 OTHER (DESCRIBE IN REM D. BELOW) D. IF (A.1) IS NOT MARKED. ENTER NAME OF SUBSTANCE STORED C. A. S. #: 111 rAelV nnuBTm IPTInLI Cu!iv lcnvCQA A ANnr. ANn AIL 74ATAPPLIESINBOXDANDE F—]1 DOUBLE WALL _.._. .___ F73 SINGLE WALL WITH EXTERIOR LINER ❑ 5 INTERNAL BLADDER SYSTEM ❑ 95 UNKNOWN A. TYPE OF SYSTEM I-2 SINGLE WALL ❑ 4 SINGLE WALL IN A VAULT ❑ 99 OTHER Atlj;;� PRESSURE A U ' BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/ FIBERGLASS REINFORCED PLASTIC B. TANK MATERIAL LY ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER A U 2 STAINLESS STEEL A U A U 6 CONCRETE A U A U 10 CATHODIC PROTECTION ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING C. INTERIOR LINING OR❑ 5 GLASS LINING �6 UNLINED F-195 UNKNOWN ❑ 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO— D.EXTERIOR ❑ i POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC CORROSION91 ❑ 5 CATHODIC PROTECTION NONE 95 UNKNOWN ❑ E:]99 OTHER PROTECTION SPILL CONTNMENT INSTALLED (YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED (YEAR) AI NO_ E. SPILL AND OVERFILL, BIC. DROPTUBE YES_ NO STRIKER PLATE YES_ NO_ DISPENSER CONTAINMENT YES_ Anel c u m i lklncol.ro lun RnTH IF APPLICABLE Ill. rIr 11Yl] 1111 VIII.I Illy 1. vn��_ .+.• •�•.�-__.. A. SYSTEM TYPE A U I SUCTION Atlj;;� PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION 1 SINGLE WALL A U 2DOUBLE 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 2 STAINLESS STEEL A U A U 6 CONCRETE A U A U 10 CATHODIC PROTECTION 3 POLYVINYL CHLORIDE (PVC)A U 4 FIBERGLASS PIPE 7 STEEL W/ COATING A U 8 100% METHANOL COMPATIBLE W/FRP 6?95 UNKNOWN A U 99 OTHER - D. LEAK DETECTION D. [:]I MECHW' L UNE LFAK CETECIOq ❑ 2 MNE TWNTNE53 3 LONnhVW31NIER5TmAl ❑ 4 ELEGTRONIC UNE ❑ TESnNO ❑ MIX4rOPNG IFAK OETECIOR 5 AUrONATC PUMP ❑ 99 OTHER SR9T0IIWN / TAAIV I CAV MCTCf TIr1M F-1 1 VISUAL CHECK 2 MANUAL INVENTORY ❑ 3 VAEMONITORING ❑ 4 AUTOMATGAUGINGIC TANK ❑ 5 GROUND MONITORING TER E]6 ANNUALTESTING RECONCILIATION ❑ 7 CONINUOUSMONITORINGINTERSTITIAL8 SIR ❑ S TANK GAUEKLY ❑ 10 T1 STING TANK ❑ 95 UNKNOWN ❑ 99 OTHER VI. TANK CLOSURE INFORMATION (PERMANENT CLOSURE IN -PUCE) 1. ESTIMATED DATE LAST USED (MO/DAYNR) 2. ESTIMATED OUANTITY OF 3. WAS TANK FILLED WITH YES ❑ NO ❑ SUBSTANCE REMAINING GALLONS INERT MATERIAL? IR TRIIF AND CORRECT THP rvnm MHO DATE TANK OWNER'S NAME (PRIMED a SIGNATURE) LOCAL AGENCY USE ONLY THE STATE I.D. NUMBER IS COMPOSED OF THE FOUR NUMtltRS OhLUW COUNTY # JURISDICTION # FACILITY # TANK # STATE I.D.# ® ®��i��96 PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE 7HIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION- FORM A, UNLESS A CURRENT FORM A HAS BEEN FILED. FORM C MUST BE COMPLETED FOR INSiALLATIOfNS. THIS FORN SHOULD BE ACDUMYANmu vi w rwl rL -- nuc 11—....,,. ...... .... --- — --.--. FORMS (6-95) • FOR0034&R7