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S STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD ; : ACU UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B 1 1 9 , 1� ' Cit If tlN r,f. COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. EMARKNLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ONSITE EM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE �L I 8 TANK REMOVED FACILITY NAME WHERE TANK IS INSTALLED. Q f L ��L C � < ! / L• L'� T I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A. OWNER'S TANK I.D.# B. MANUFACTURED BY: �► V1 L/Z 3. D+U YL ) C. DATE INSTALLED(MOIDAYNEAR) D. TANK CAPACITY IN GALLONS! vad-4W II.TANK CONTENTS IFA-1 IS MARKED,COMPLETE ITEM C. ❑ la REGULAR UNLEADED ❑ 3 DIESEL C I 6 AVIATION GAS A 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C. 4 GASAHOL 1 PRODUCT ibPREUM A ❑ F-] 7 METHANOL ❑ 2 PETROLEUM � 80 EMPTY UNLED D 5 JET FUEL ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED ❑ 99 OTHER {DESCRIBE IN ITEM D. BELOW) 0. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S.#: III, TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.B,AND C,AND ALL THAT APPLIES IN BOX D AND E ❑ A. TYPE OF 99 OTHER 1 DOUBLE WALL F73 SINGLE WALL WITH EXTERIOR LINER El 95 UNKNOWN SYSTEM � P SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B. TANKF-:] 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM E] 6 100% METHANOL COMPATIBLE WFFRP MATERIAL ❑ 5 CONCRETE (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 6 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER LINING �- IS LINING MATERIAL COMPATIBLE WITH 100Yk 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) K epi OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) L*p H IV,PIPING INFORMATION CIRCLE A IFABOVE GROUND OR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION A& 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A,�U�1 SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH AID 95 UNKNOWN A U 99 OTHER IL`!i' C. MATERIAL AND A 1 RARE 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 STEEL W/COATING A U 8 100%. METHANOL COMPATIBLE WIFRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION 1 AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TGHTNESS TESTING ❑ 9 MONITORING ❑ OTHER V.TANK LEAK DETECTION 1 VISUAL CHECK2 INVENTORY RECONCILIATION ❑ 3 VADOZE MONITORING E:] 4 AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING 6 TANK TESTING F-17 INTERSTITIAL MONITORING ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER VI,TANK CLOSURE INFORMATION I.ESTIMATED DATE LAST USED(MOIDAY(YR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES ❑ NO ❑ SUBSTANCE REMAINING GALLONS I INERT MATERIAL? THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANT'S NAME q r � DATEr Q (PRINTED&SIGNATURE) ��IS �[( G r LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW CIlv� COUNTY# JURISDICTION# FACILITY# TANK# STATE I.D.# n] 'Z (� 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. FORfl9t34B-RS 10