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v v STATE OFCALIFORWA STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B j COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM C ❑ 1a REGUL R 3 DIESEL ❑ 6 AVIATIONGAS MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ON SIT] ONE ITEM ❑ 2 INTERIM PERMIT UNLEADED 5 JETFUEL ❑ O 2 LEADED ❑ 99 OTHER (DESCRIBE IN ITEM D. BELOW) 4 AMENDED PERMIT ❑ 8 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED DBAOR FACILITY NAME WHERE TANK IS INSTALLED: 6?,Ag'/✓ v/G'i7a2 444_ 4--� MATERIAL I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A. OWNER'S TANK I.D.• B. MANUFACTURED BY: - L C. DATE INSTALLED (MO/DAY/YEAR) /GT 7 D. TANK CAPACITY IN GALLONS: �Zr ppO II.TANKCONTENTS IFAAIS MARKED, COMPLETE ITEM C. A. 1 MOTOR VEHICLE FUEL ❑ 4 OIL 8. C ❑ 1a REGUL R 3 DIESEL ❑ 6 AVIATIONGAS ❑ PETROLEUM ❑ 80 EMPTY ` PRODUCT 10 PREMIUM 4 GASAHOL 7 METHANOL O E:] ❑ 3 CHEMICAL PROWCT ❑ BS UNKNOWN ❑ 2 WASTE UNLEADED 5 JETFUEL ❑ O 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_ A ANN r. ANN &II THAT APm icR 1. Rnv n nunc A. TYPE OF DOUBLE WALL ❑1 E::]1 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM Imo`, 2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER B. TANK nk 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 (PrimaryTank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER A U ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING 4 PHENOLIC LINING C. INTERIOR ❑ 5 GLASS LINING 8 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER 99 OTHER IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES _ NO— ❑ 1 AUTOMATIC LINE LEAK D. CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE p❑:] ` ' 95 UNKNOWN `Y O 99 OTHER E. SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED (YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED (YEAR) IV. PIPING INFORMATION clAciP A IPARnVCro9nuNnnR D A: uuncRroniinin -—A-1 A-1 ,... A. SYSTEM TYPE A 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION I© 1 SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 90 OTHER C. MATERIAL AND A U 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 W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A(3>5 UNKNOWN A U 99 OTHER D. LEAK DETECTION ❑ 1 AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING ❑ ❑ 99 OTHER MONITORING V. TANK LEAK DET 1 VISUAL CHEC LJ��/ VENTORY RECONCILIATION ❑ 3 VADOZE MONITORING ❑ 4 AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING e TANK TESTING7 INTERSTITIAL MONITORING ❑ 91 NONE ❑ 95 UNKNOWN ❑ W OTHER 1. ESTIMATED DATE LAST USED (MOIDAY/YR) 2. ESTIMATED QUANTITY OF SUBSTANCE REMAINING THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY APPLICANT IGWMEDA SIGNATUREI 3. WAS TANK FILLED WITH YES ❑ NO❑ GALLONS INERTMATERIAL7 AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT LOCAL AGENCY USE ONLY Int SIArF I.D. NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY # JURISDICTION # FACILITY # TANK # DC7 I STATE I.D.# m 7 ® 7l5 PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT E%PIRATION DATE z THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION • FORMA, UNLESS A CURRENT FORMA HAS BEEN FILED. rac I Nib M"M Wil N '-% LUUAL AUtNUT IMFLtMtN I ING I RE UNDERGROUND STnRAGE TANK REGULATIONS FORM (12-91) `� *ftqw 1`01 /846