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• • eegooa e c STATE OF CALIFORNIA ^e STATE WATER RESOURCES CONTROL BOARD s ° UNDERGROUND STORAGE TANK PERMIT APPLICATION• FORM B w�� ' COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM n c�`��°a�� MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ONSITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURETANK REMOVED DBAOR FACILITY NAME WHERE TANK IS INSTALLED: I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A. OWNER'S TANK I.D.# v, � B. MANUFACTURED BY: /I,,, P_ C. DATE INSTALLED(MO/DAV/YEAR) G. D. TANK CAPACITY IN GALLONS: /,"Z) ILTANKCONTENTS IFA-11S MARKED,COMPLETE ITEM C. A. 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C. F-118UNLEA ED 3 DIESEL ❑ 6 AVIATION GAS ❑ 2 PETROLEUM ❑ 80 EMPTY i PRODUCT E:] 1b PR EIUM ❑ 5 JET FUEL 4 GASAHOL ❑ 7 METHANOL ❑ 3 CHEMICALPRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE 2 LEADED ❑ 99 OTHER (DESCRIBE IN ITEM D. BELOW) D. 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 -7 f+\ A. TYPE OF ❑ 1DOUBLE WALL F-13 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN [� / SYSTEM SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER B. TANK BARE STEEL F-] 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEELCLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ B 700% METHANOL COMPATIBLE W/FRP (PrlmaryTank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED EKYD LINING 7] 3 EPDXY LINING E:] 4 PHENOLIC LINING C.INTERIOR F—] 5 GLASS LINING 6 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER LINING IS LINING MATERIAL COMPATIBLE WITH 100% 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 IV.PIPING INFORMATION CIRCLE A IFABOVEGROUNDOR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A 1 SUCTION A U 2 PRESSURE A U 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 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 6 CONCRETE A U 7 STEELW/COATING A U 6 100% METHANOL COMPATIBLEW/FRP PROTECTION AUV 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 TIGHTNESS TESTING ❑ 3 MONRORINGL ; " OTHER D V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VAPOR MONITORING[] 4 AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING ❑ 6 TANK TESTING ❑ 7 INTERSTITIAL MONITORING �91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION I.ESTIMATED DATE; ��D(MO/DAV/YR) 2.ESTIMATED OUANTITY OF / D GALLONS 3 WASNERTMATEDWIITH YES ❑ NO 7] CLQ. SUBSTANCE REMAINING THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANPS NAME DATE (PRINTED a SIGNATURE( LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW STATE LDAI COUNTY# JURISDICTION# FACILITY# TANK# 9 PERMITNUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE '4 Z 9tj 92l FORM B (9-90) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORM A HAS BEEE/ENN�FILED. // /// FORCW B-S4