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*v. I STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B t� COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM y O i NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED MARK ONLY 2 INTERIM PERMIT O 4 AMENDED PERMIT ❑ 8 TEMPORARY TANK CLOSURE ❑ B TANK REMOVED ONE [TEM ❑ DBA OR FACILITY NAME WHERE TANK IS INSTALLED: I. TANK DESCRIPTION COMPLETE ALL ITEMS-- SPECIFY IF UNKNOWN B. MANUFACTURED BY: A. OWNER'S TANK I D /� TANK CAPACITY IN GALLONS (ArJv C. DATE INSTALLED (MO/DAVA'EAR) / D _ ILTANK CONTENTS IFA-11SMARKED,CUMFLtIl'It-1. tAREGULAR n 3 DIESEL O 6AVIATIONGAS A � MOTOR VEHICLE FUEL ❑ 4 OIL B. C' ® UNLEADED L�JI q SSL 7 METHANOL 2 PETROLEUM ❑ PREMIUM fb EMPTY �1 PRODUCT ❑ 10UNLEADED ❑ 5 JETFUEL ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN 2 WASTE ❑ 2 LEADED O g9 OTHER (DESCRIBE IN ITEM D. BELOV O. IF (A.1) IS NOT MARKED. ENTER NAME OF SUBSTANCE STORED C. A. S. III, TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A, R. ANU U. RAU ALL I nA i -P-11, - 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN A. TYPE OF SYSTEM 2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) 99 OTHER A U 99 OTHER �1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS 4 STEEL CLAD W/ FIBERGLASS REINFORCED PLASTIC B. TANK ❑ 5 CONCRETE � 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM 9 100% METHANOL COMPATIBLE W/FRP MATERIAL (PrimWTAnk) ❑ 9 BRONZE Q 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER LEAK DETECTION ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING C. INTERIOR ❑ 5 GLASS LINING NL 6 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER LINING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? VES_ NO_ ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC D. CORROSION PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE �95 UNKNOWN ❑ 99 OTHER E. SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED (YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED (YEAR) _ -__..AeoI Iceol c vt Iv1� IV. 1'IYv lnrnnw IIY 1i,..ir..o...�................ _.. _..__.._..____.__ rnic A. SYSTEM TYPE A U 1 SUCTION U PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A U SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 0.5 UNKNOWN A U W 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 10 CATHODIC PROTECTION 3 POLYVINYL CHLORIDE (PVC)A U 7 STE``L,,W`/COATING A U A(/E��)96 UNKNOWN A U 4 FIBERGLASS PIPE B 100% METHANOL COMPATIBLE W/FRP 99 OTHER LEAK DETECTION L]1 AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING ❑ ] WIMTIJAD. MONRORING ❑ 90 OTHER J. TANK LEAK DET Q 1 VISUAL CHEK � 2 NVENTORY RECONCILIATION F-13 VADOZE MONITORING O 4 AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING ML 6 TANK TESTI 7 INTERSTITIAL MONITORING ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER 1. ESTIMATED DATE LAST USED(MO/DAYIVR) I 2 SUBSTANC ATED DUANTITY OF GALLONS 3 WAS ERT MATEFILLED WITH YES [:]NO ❑ REMATHIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT (PRINTED 6 SIGNATURE) LOCAL AGENCY USE ONLY THE STATE I.D. NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY # JURISDICTION # FACILITY # TANK # STATE I.D.# m= I 1 1(1,7 LLL -L 11 IN r��j PERMIT NUMBER PERMIT APPROVED BYIDATE PERMIT EXPIRATION DATE C-�rk 1Qw1jpj THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION • FORM A, UNLESS A CURRENT FORM A HAS BEEN FILED. FORM B (12-91) FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS T 10 FOR 8416