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yOUN 0'w STATE OFCALIFORNIAp STATE WATER RESOURCES CONTROL BOARDrUNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B `-A YP .COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. �"'�� MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION 7 PERMANENTLY CL E ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSUREB TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: ZR 0( td A l X Vf Mal ((4' I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A. OWNER'S TANK I.D.# 14 B. MANUFACTURED BY: u C. DATE INSTALLED(MO/DAY/YEAR) N 1 D. TANK CAPACITY IN GALLONS: ILTANKCONTENTS IFA-11S MARKED,COMPLETE ITEM C. A. Xj 1 MOTOR VEHICLE FUEL ❑ 4 OIL I 1.REGULAR C' ❑ UNLEADED ® 3 DIESEL ❑ 6 AVIATION GAS ❑ 2 PETROLEUM ❑ 80 EMPTY ❑ 1 PRODUCT ❑ 1bPREM IUM UNLEAD D ❑ 5 ET FUELAHO ❑ 7 MET ANOL ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE 2 LEADED ❑ gg OTHER (DESCRIBE IN ITEM . BELOW) D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S.# III. TANK CONSTRUCTION MARKONE ITEM ONLY IN BOXESA,B,ANDC,ANDALLTHATAPPLIES IN BOXDANDE A. TYPE OF m❑ 1 DOUBLE WALL E] 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM W 2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER B. TANK C� 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ q STEEL CLAD W/FIBERGLASS REINFOHCEI I PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ B 100% METHANOL COMPATIBLE W/FRP (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING 3 EPDXY LINING 4 PHENOLIC LINING C.INTERIOR ❑ 5 GLASS LINING til 6 ❑ LINING �' UNLINED ❑ 95 UNKNOWN 99 OTHER IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO— D.CORROSION ❑ i 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 IFABOVEGROUNDOR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A 1 SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHE C. MATERIAL AND A 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 6 CONCRETE A U 7 STEELW/COATING A U 6 100% METHANOL COMPATIBL W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION [:7] 1 AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING 3 ❑ MONITORING ❑99 OTHER ODUP V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VADOZE MONITORING ❑ 4 AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MO ITORING ❑ 6 TANK TESTING ❑ 7 INTERSTITIAL MONITORING 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION 1.ESTIMAED DATE LAST USED(MO/DAY/9R) 2.ESTIMATED QUANTITYOF 7 3.WAS TANK FILLED WITH UK SUBSTANCE RLYAINING GALLONS INERTMATERIAL? YES ❑ N THIS FORM HAS BEEN COMPLETED UNDER PENALTY O PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND COR ECT APPLICANTS NAME � /� (PRIN!SIGNATURE) A� la( Lb I� • DATE �/� /G 7 KK 1/] / LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER I OMPOSEDOFTHE FOUR NUMBERS BELOW STATE I.D.# COUNTY# JURISDICTION# FACILITY# TANK# m � I�T� mTi�r� PERMIT NUMBER PERMIT APPROVED BY/DATE LL� 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. • CJ', F01100 13 R5 �D_ I