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..aces STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD a o UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B o > , COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM MARK ON Y ® 1 N PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENT CLOSED ON TE ONE ITE ❑ INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 6 TANK REM ED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: -2, Q /' tz CL I. TANK DESCRIPTION COMPLETE ALL ITEMS-. SPECIFY IF UNKNOWN A. OWNER'S TANK I.D.# 3735 1 B. MANUFACTURED BY: OWED CORNING C. DATE INSTALLED(MOIDAYIYEAR) 6/24/91 D. TANK CAPACITY IN GALLONS: 750 ILTANKCONTENTS IFA-1 ISMARKED.COMPLETE ITEM C. ❑ I MOTOR VEHICLE FUEL ® 4 OIL B. C. ❑ 1a3 DIESEL ❑ 6 AVIATION GAS A. UNLEADED 4 GASAHOL 2 PETROLEUM 80 EMPTY 1 PRODUCT ibP UNLEADED ❑ 5 FUEL ❑ 7 METHANOL ❑ ❑ ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN WASTE ❑ 2 LEADED gg OTHER (DESCRIBE IN ITEM D. BELOW) D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S.s: III, TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.B,AND C,AND ALL THAT APPLIES IN BOX D A. TYPE OF I DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM ❑ 2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER ❑ 1 BARE STEEL ❑ 2 STAINLESS STEEL E293 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B. TANK 'MATERIAL 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ B 100°x. METHANOL COMPATIBLE WlFRP ❑ i0 GALVANIZED STEEL 9FIBERGLASS {Primary Tank) 5 UNKNOWN 99 OTHER I❑ 9 BRONZE ❑ ❑ ❑ ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING C.INTERIOR ❑ 5 GLASS LINING ❑ 6 UNLINED ❑ 96 UNKNOWN ❑ 99 OTHER LINING IS LINING MATERIAL COMPATIBLE WITH 1009E METHANOL? YES-X— NO— D.CORROSION ❑ i POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER 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 (K 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL A IK 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND A U 1 BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE IPVCI A X 4 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 9 CONCRETE A U 7 STEEL Wl COATING A U B 100% METHANOL COMPATIBLE WIFAP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER ERSTITiAL D. LEAK DETECTION t AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE 7VGHTNESS TESTING ❑ 7 MONITORING ❑ 99 OTHER V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VAPOR 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 DATE LAST USED(MOIDAYIYR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES ❑ 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 APPLICANTS NAME DA (PRINTED&SIGNATURE) LOCAL AGENCY-IISE-0Nl.Y THE STATE I.D.NUMBER IS CO OSED FTH FOIlR NUMBERS BELOW ~� COUNTY# JURISDICTION# FACILITY# TANK# STATE 04 �❑❑ d �' © Q © 5=/ PERMIT NUMBER --' PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE FORM B (g-go THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. F0RWMB.A4 oRGA � 1