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0 0 OVaCt9 STATE OFCALIFORNIA STATE WATER RESOURCES CONTROL BOARD ` *o UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM B COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED ON SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT TEMPORARY TANK CLOSUREe TANK REMOVED DBA Oq FACILITY NAME WHERE TANK IS INSTALLED: Z I-// Lj/ J�S 1Z G I. TANK DESCRIPTION COMPLETE ALL ITEMS-SPECIFY IF UNKNOWN A. OWNER'S TANK I.D.# v / _ S. MANUFACTURED BY: /. C. DATE INSTALLED(MO/DAY/YEAR) Lle i D. TANK CAPACITY IN GALLONS: l ILTANKCONTENTS IFA-11S MARKED,COMPLETE ITEM C. A. 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C. ❑ 1aUREGULARN EA ED 3 DIESEL ❑ 6 AVIATIONGAS ❑ 2 PETROLEUM ❑ 80 EMPTY CK 1 PRODUCT ❑ 1b PREMIUM 4 3 CHEMICAL PRODUCT GASAHOL 7 METHANOL UNLEADED ❑ 5 JETFUEL ❑ Q ❑ 95 UNKNOWN O 2 WASTE _ 2 LEADED 98 OTHER (DESCRIBE IN ITEM D. BELOW) O. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S.#: III. TANK CONSTRUCTION MARKONEITEMONLYINSOXESA,B,ANDC,ANDALLTHATAPPLIESINBOXO NDE 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 B. TANK ❑ 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP (PrimaryTNk) ❑ 9 BRONZE O 10 GALVANIZED STEEL 0 u 95 UNKNOWN ❑ 99 OTHER C.INTERIOR F-11 RUBBER LINED E] EPDXY LINING 2 ALKYD LINING 3 4 PHENOLIC LINING ❑ ❑ LINING ❑ 5 GLASS LINING ❑ 6 UNLINED (1l. 95 UNKNOWN ❑ —4-1 99 OTHER 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 IFS95 UNKNOWN O 99 OTHER E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) W.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION A U 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 95 UNKNOWN A U 99 OTHER C. MATERIAL AND A U 1 BARE STEEL p U 2 STAINLESS STEEL p U 3 POLWINYL CHLORIDE(PVC)A U CORROSION A U S ALUMINUM 4 FIBERGLASS PIPE A U 6 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 PROTECTION95 UNKNOWN A U 99 OTHER D. LEAK DETECTION 61 E] 1 AUTOMATIC LINE LEAK DETECTOR E] 2 LINE TIGHTNESS TESTING 3 MONRORING ❑ B8 OTHER V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VADOZE MONITORING ❑ 4 AUTOMATIC TANK GAUGING O 5 GROUNDWATER MONITORING ❑ 6 TANK TESTING ❑ 7 INTERSTITIAL MONITORING ❑ 91 NONE 95.� UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION 1.ESTIMATED DATE LAST USED(MO/DAY/VR) 2.ESTIMATED QUANTITY OF SUBSTANCE REMAINING GALLO3.WAS TANK FILLED WITH YES ❑ NO ❑ NS INERT MATERIAL? THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLED APPLICANTS NAME GE, IS TRUE AND CORRECT (PRINTED d SIGNATURE) DATE LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW STATE 104 CNTY# JURISDICTION III, TANK FACILITY 7 N„ PERMIT NUMBER PERMITAPPROVED BYIDDATE PERMIT EXPIRATION DATE THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FOgM A,UNLESS A CURRENT FORMA HAS BEEN FILED. FILE THIS FORM WITH--,LOCAL AGENCY IMPLEMENTING THE UNDERGROUNDS GE TANK REGULATIONS FORM B (12-91) FORORIIBRS