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STATE OF CALIFORNIA • W• '°'"' '?, STATE WATER RESOURCES CONTROL BOARD i Wim, UNDERGROUND STORAGE TANK PERMIT APPLICATION • FORM B a a 0-1 COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM, MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ONSITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ B TEMPORARY TANK CLOSURE TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: Gm/dl " jenAn 30 /�✓OL/� Aw I. TANK DESCRIPTION COMPLETE ALL ITEMS-- SPECIFY IF UNKNOWN A. OWNERS TANK I.D.# B. MANUFAC RED BY: C. DATE INSTALLED(MO/DAY/YEAR) v D. TANK CAPACITY IN GALLONS: 5 > ILTANKCONTENTS IFA-1 IS MARKED,COMPLETE ITEM C. to REGULAR 3 DIESEL A. 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C' ❑ UNLEADED ❑ e AVIATION GAS ,..��,,,, 4 GASAHOL ❑ 2 PETROLEUM ❑ 60 EMPTY �1 PRODUCT "PREMIUM ❑ 7 METHANOL 4/Pu{T�\ UNLEADED ❑ 5 JET FUEL ❑ 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.4: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.B,AND C,AND ALL THAT APPLIES IN BOX D AND A. TYPE OF y❑ 11 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER F] 95 UNKNOWN SYSTEM LJ a SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTEDTANIQ ❑ 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 ❑ B 100% METHANOL COMPATISLE W/FRP (PrimaryTank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL 95 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING C.INTERIOR ❑ 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 CS 95 UNKNOWN ❑ 99 OTHER E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) IV.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 AU 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 STEEL W/COATING A U S 100% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION kv5 UNKNOWN A U99 OTHER D. LEAK DETECTION ❑ 1 AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING ❑ 3 MONITORINGINTERSTITIAL y1,J99OTHER L�• V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VADOZE 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 1.ESTIMATED DA EAS LUS (MO/DAY/YR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH g /,?..�y SUBSTANCE REMAINING Q GALLONS INERT MATERIAL? YES E] NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANTS NAME DATE (PRINTEGB SIGNATURE) ImLOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OFTHE F NUMBERS v v COU NTY# JURISDICTION# FACILITY# TANK# STATE I.D.# ® (p S S 3 c i &/j PERMITNUMBER PERMIT APPROVED B /DATEPERMIT IRATION DATE THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION• RRENT FORM A HA FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS FORME (12-91) • n FOROW&IIS