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R • • ♦V��.m. co STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION • FORM B 91 COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM MARK ONLY ❑ EW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TE ONE ITEM 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOV[D DBA OR FACILITY NAME WHERE TANK IS INSTALLED: I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A. OWNER'S TANK I.D.# �d 0. MANUFACTURED BY: 1 C. DATE INSTALLED(MO/DAYNEAR) _1 D. TANK/CAPACITY IN GALLON /1 ILTANKC TENTS IFA-11S MARKED.COMPLETE ITEM C. - MOTOR VEHICLE FUEL ❑ 4 OIL B. C. to GULAR e 3 IESEL ❑ 8 AVIATI N GAS A i UNLEADED q GASAHOL E:] 7 METHANOL EMPTY E O3 CHEMICAL PRODUCT F-11 PRODUCT ib PREMIUM 2 PETROLEUM 95 UNKNOWN E:] 2 WASTE E] 2 LEADE00 99 JOTHERL(DESCRIBE IN ITEM D. BELOW) D. IF(A.I)IB NOT MARKED. EN R NAME OF SUBSTANCE STORED C.A.S.#: III. TANK CONSTRU ION MARK ONE ITEM ONLY IN BOXES0.8.AND C,AND ALLTHAT APPLIESIN BOXD 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN A. TYPE OF ❑ SYSTEM ❑ 2 SINGLE WALL s SECONDARY CONTAINMENT (VAULTED TANIq E 0B ER ❑ 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS 4 STEEL CUD W/FIBERGLASS REINFORCED PLASTIC B. TANKF76 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 1009: METHANOL COMPATIBLE W/FRP MATERIAL ❑ 5 CONCRETE (PrlmaryTank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 996 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED ❑ 2 ALKYD LININGnye EPDXY LINING ❑ 4 PHENOLIC LINING C.INTERIOR ❑ 5 GLASS LINING ❑ 6 UNLINED 1 96 UNKNOWN ❑ 99 OTHER LINING IS LINING MATERIAL COMPATIBLE WITH t00x METHANOL? YES_ NO_ D.CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE ❑95 UNKNOWN ❑ 99 OTHER IV.PIPING INFORMATI CIRCLE A IFABOVEGROUNDOR U IF UNOERGROUND,80TH IF APPLICABLE A. SYSTEM TYPE qv 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER S. CONSTRUCTION A U 1 SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A U95 U OWN A U 9a OTHER C. MATERIAL AND A U I BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) U 6 FIBERGLASS PIPE A U 6 CONCRETE A U 7 STEEL W/COATING A U 8 100% METHANOL COMPATIBLE W/FRP CORROSION A U 5 ALUMINUM PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99-OTHER- D. LEAK DETECTION F-] 1 AUTOMATIC LINE LEAKDETECTOR [—] 2 LINE TIGHTNESS TESTING ❑ MONITORING OTHER V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ INVENTORY RECONCILIATION ❑ 3 VAPOR MONITORING❑ 4 AUTOMATIC TANK GAUGING ❑ 5 GROUNDWATER MONITORING ❑ 6 TATESTING 7 NK INTERSTITIAL MONITORING ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION 1.ESTIMATED DATE LAST USED(MO/DAY/YR) 2.ESTIMAD OUANTITY OF 3.WAS TANK FILLED WITH YES ❑ NO❑ SUB STANTECE OR GALLONS INERT MATERIAL? THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANT'S NAME (PRINTED ASIGNATDRE) 3 , (,:- 0 DATE � LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY# TANK# COO STATE I.D.# Lif 0 PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE,,;, �aFOOR�M�BB (,(S go))) THIS FORM MUST BE ACCOMPANIED BY A PERMIT I T APPLC�A/TION•FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. -ra4lLk