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STATE OFCAUFORIBA "pp9 r. STATE WATER RESOURCES CONTROL BOARD of UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B `� s COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. `'�..a.��` � o MARK ONLY ❑ 1 NEW PERMIT O 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ONE REM ❑ 2 INTERIM PERMIT 4 AMENDED PERMIT ❑ S TEMPORARY TANK CLOSURE DBA OR FACILITY NAME WHERE TANK IS INSTALLED: ypp lZ,oe L TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A. OWNERS TANK 1. D. S. MANUFACTURED BY: C. DATE INSTALLED (MCVDAV/YEAR) D. TANK CAPACITY IN GALLONS: ILTANKCONTENTS IFA-11SMARKED, COMPLETE ITEM C. ❑ 4 SECONDARY CONTAINMENT (VAULTEDTANK) A , 1 MOTOR VEHICLE FUEL ❑ 4 OIL g /a REGULAR C ❑ ❑ 2 PETROLEUM ❑ BD EMPTY 1 PROOUCT UNLEADED JUM ❑ ibPREMUNLEADED ❑ 3 CHEMICAL PRODUCT O 95 UNKNOWN O 2 WgSTE ❑ 2 LEADED D. IF (A.1) IS NOT MARKED. ENTER NAME OF SUBSTANCE STORED ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN III. TANK CONSTRLIrTInN _.._........__..__ O 7 PERMANENTLY CLOSED ONSITE O B TANK REMOVED r-_—1 3 DIESEL 6 AVIATION GAS -4 GASAHOL ❑ 5 JET FUEL ] METHANOL 99 OTHER (DESCRIBE IN ITEM D. SELOV C. A. S.#: A. ❑ 1 DOUBLE WALL E A. TYPE OF A U ❑ 3 SINGLE WALL WITH EXTERIOR LINER O 95 UNKNOWN SYSTEM 2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTEDTANK) ❑ 99 OTHER B. TANK 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/ FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 9 POLYVINYL CHLORIDE ❑ 7 ALUMINUM B 100% METHANOL COMPATIBLE W/FRP (PrimaryTwk) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ W OTHER C. INTERIOR ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING 3 EPDXY LINING ❑ 4 PHENOLIC LINING LINING ❑ 5 GLASS LINING 6 UNLINED ❑ 95 UNKNOWN 99 OTHER IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES _ NO_ D.CORROSION ❑ 1 POLYEhIYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP O 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE 1A95 UNKNOWN ❑ 99 OTHER E. SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED (YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED (YEAR) A. SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND CORROSION PROTECTION A U A U A U 1 BARE STEEL 5 ALUMINUM 9 GALVANIZED STEEL A U A U A U 2 STAINLESS STEEL A U 6 CONCRETE A U /0 CATHODIC PROTECTION 3 POLYVINYL CHLORIDE (PVC)A U W/COATING A U 7 fa)" C ls UNKNOWN A U 4 FIBERGLASS PIPE 00 B 1% METHANOL COMPATIBLE W/FRP 99 OTHER D. LEAK DETECTION ❑ 1 AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING ❑ 3 MONITORING ❑ 99 OTHER V. TANK LEAK DET r�❑� 1 VISUAL C CK INVENTORY RECONCILIATION F]3 VADOZE MONITORING E::]4 AUTOMATIC TANK GAUGING ❑ 5 GROUNDWATER MONITORING (I 6 TANK T ;Tl -NZ= 7 INTERSTITIAL MONITORING ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER 1. ESTIMATED DATE LAST USED (MO/DAY/YR) 2. ESTIMATED QUANTITY OF 3. WAS TANK FILLED WITH VES ❑ NO ❑ SUBSTANCE REMAINING GALLONS INERT MATERIAL? THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT (PRINTED & SIGNATURE) LUL;AL AUENUY UJt UNLY THE STATE I.D. NUMBER IS COMPOSED OFTHE FOUR NUMBERS BELOW STATE 04COUNTY # JURISDICTION # FACILITY # TANK # QQ2- m 7 1 1 d Ir PERMITNUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE -& IZ12 �IG FORM (12-91) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION -FORMA. UNLESS A CURRENT FORMA HAS BEEN FILED FILE THIS FORM WITH TWE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STnRAGE TANK REGULATIONS \K FORO#N4R6