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a STATE OF CALIFORNIA s STATE WATER RESOURCES CONTROL BOARDol # �� UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY 1 NEW PERMIT C� 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION O 7 PERMANENTLY CLOSED ON TE ONE ITEM ❑ 2 INTERIM PERMIT td,\*`' 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE 8 TANK REMOVED 5 DBA OR FACILITY NAME WHERE TANK IS INSTALLED: 2 1. TANK DESCRIPTION COMPLETE ALL ITEMS-- SPECIFY IF UNKNOWN EC. NER'S TANK I.D.# 373S1A B. MANUFACTURED BY: OWEN CORNING TE INSTALLED(MOIDAYlYEARI f3 4 9 L D. TANK CAPACITY IN GALLONS: 750 ILTANKCONTENTS IFA-1 IS MARKED,COMPLETE ITEM C. C ❑ 1a REGULAR ❑ 3 DIESEL ❑ 6 AVIATION GAS A ❑ l MOTOR VEHICLE FUEL 4 OIL B. UNLEADED ❑ 4 GASAHOL 7 METHANOL ❑ PREMUM 2 PETROLEUM 80 EMPTY ❑ 1 PRODUCT ❑ 1bUNLEAI ❑ DED 5 FUEL ❑ ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN V WASTE O 2 LEADED gg OTHER (DESCRIBE kN ITEM D. BELOW) ry C.A.S.# IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED � 1 III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.B,AND C,AND ALL THAT APPLIES IN BOX D 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN A. TYPE OF ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK] ❑ 99 OTHER SYSTEM ❑ 2 SINGLE WALL 1 BARE STEEL ❑ 2 STAINLESS STEEL 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B. TANK ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 10(1°6 METHANOL COMPATIBLE WIFRP MATERIAL ❑ 5 CONCRETE FIBERGLASS (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER _!:� Q 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— 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC ❑ D.CORROSION ❑95 UNKNOWN ❑ 99 OTHER PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND,BOTH IF APPLICABLE rCORRIOSION TYPE A U 1 SUCTION A U 2 PRESSURE A X 3 GRAVITY A U 99 OTHER UCTIbN A U 1 SINGLE WALL A IK 2 DOUBLE WALL A U 3 LINEDTRENCH A U g5 UNKNOWN A U 99 OTHERCON AL AND A U 1 BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVCIA d FIBERGLASS PIPE A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEELW/COATING A U 8 100°/ METHANOL COMPATIBLE WIFRPA U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHERCTION 3INTERSTITIAL 99 OTHER D. LEAK DETECTION 1 AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TGHTNESS TESTING ❑ MONITORING V.TANK LEAK DETECTION 1 VISUAL CHECK E–] 2 INVENTORY RECONCILIATION ❑ 3 VAPOR MONITORVNG❑ d AUTOMATIC TANK GAUGING 5 GROUND WATER MONITORING 6 TANK TESTING � 7 INTERSTITIAL MONITORING ❑ 91 NONE Ll 95 UNKNOWN ❑ 99 OTHER E:] VI.TANK CLOSURE INFORMATION �WANK FILLED WITH2.ESTIMATED QUANTITY OF RT MATERIAL? YES ❑ NO❑ i.ESTIMATED DATE LAST USED(MdIDAYlYR) SUBSTANCE REMAINING GALLONS THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT DATAPPLICANT'S NAME �+ "J I J JZ (PRINTEC&SIGNATURE) HAV212 LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS CO OSED F TH FO R NUMBERS BELOWTANK#OQ W COUNTY# JURISDICTION# FACILITY# STATE I.D.# PERMIT APPROVED BYlDATE rRM IT EXP) ATI DA E PERMIT NUMBER FORM B (9-90) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. FOF100346 R4 0