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neo ^ e r-: STATE OF CALIFORNIA c°'. STATE WATER RESOURCES CONTROL BOARD i� ,�; »o UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B y� 3 0 ..ACOMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. �"°"� MARK ONLY ❑ i NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED D DBAOR FACILITY NAME WHERE TANK IS INSTALLED: 050 f, MillZAJ A JCI I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN � V A. OWNER'S TANK I.D.• B. MANUFACTURED BY: ft C. DATE INSTALLED(MO/DAYNE R) 01- D. TANK CAPACITY IN GALLON!". ILTANKCONTENTS IFA-11S MARKED.COMPLETE ITEM C. A. 1 MOTOR VEHICLE FUEL O 4 OIL B. C la REGULAR O 3 DIESEL O 6 AVIATION GAS�1 �I UNLEADED o 4 GASAHOL ❑ 2 PETROLEUM ❑ 80 EMPTY F< PRODUCT ❑ 1bUNLMIDM ❑ 5 JETFUEL ❑ 7 METHANOL ❑ 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.# III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A,B,AND C,AND ALL THAT APPLIES IN BOX D AND A. TYPE OFI)p 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM ^❑ 2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER B. TANK ❑ 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS 4 STEELCLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL O 5 CONCRETE O 6 POLYVINYL CHLORIDE O 7 ALUMINUM 08 100% METHANOL COMPATIBLE W/FRP (Primary Tank) ❑ 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 F;;Qe6 UNLINED O 95 UNKNOWN O 99 OTHER LINING IS LINING MATERIAL COMPATIBLE/WITH 10 METHANOL? YES NO— D.CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE O95 UNKNOWN ❑ 99 OTHER E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR) I OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) IV.PIPING INFORMATION CIRCLE A IFABOVEGROUNDORU IF UNDERGROUND,BOTH IF APPLICA13LE A. SYSTEM TYPE A U 1 SUCTION p PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL A DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND A U 1 BARE STEEL At 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 8 100% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN p 99 OTHER D. LEAK DETECTION Xl AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING ❑ 31 MONITORING E] 99 OTHER V.TANK LEAK DETECTION F � 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VADOZE MONITORING [-] 4 AUTOMATIC TANK GAUGING ❑ 5 G ._ ROUND WATER MONITORING 6 TANK TESTING ❑ 7 INTERSTITIAL MONITORING ❑ 91 NONE ❑ 95 UNKNOWN 99 1 VI.TANK CLOSURE INFORMATION 1.ESTIMATED E ST USED(MO/DAYNR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH SUBSTANCE REMAINING GALLONS INERT MATERIAL? YES ❑ NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANTS NAME DATE (PRINTED a SIGNATURE) LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY# TANK# STATE I.D.# ja = � 1,516151-711711 ,5 n�� PERMIT NUMBER PERM IT APPROVED BYIDATE PERMIT EXPIRATION DATDATELL-��-.L-I-�J FORM B (7-91) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORM A,UNLESS A CURRENT FOR'MT A HAS BEEN LFILED. -13- /aJ F0R0WIbR5 A�