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STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B w „psi, 0 a COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION❑ PERMANENTLY CLOSE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: D I. 1 ANK DESGHIPTION COMPLETE ALL ITEMS -- SPECIFY IF UNKNOWN A. OWNER'S TANK 1. D. # S. MANUFACTURED BY:1/I Io / 1 C. DATE INSTALLED (MO/DAY/YEAR) D. TANK CAPACITY IN GALLONS: Y 1 - _ TANI[Cf1NTGNTC pipa c, S 0 )CJ A. Yl MOTOR VEHICLE FUEL ❑ 4 OIL B. C. la REGULAR ❑ ❑ ❑ 6 AVIATION GAS ❑ 2 PETROLEUM E]80 EMPTY PRODUCT [��bPREMIUM ❑ 4 GASAHOL ❑ 7 METHANOL ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE UNLEADED ❑ 5 JET FUEL ❑ 2 LEADED ❑ 99 OTHER (DESCRIBE IN ITEM D. BELOW) D. IF (AA) IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C. A. S. #: III. TANK CONSTRUCTION IAAaK nNF ITPIA nM[ vim PnYrQ A 0 Agin r AA- AI I —AT A— ICC IA — n A. TYPE OF ❑ 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM 5� 2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER B. TANK 1 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/ FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL 95 UNKNOWN ❑ 99 OTHER I IAL MONITORING OTHER ❑ 1 RUBBER LINED F-]2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING C. INTERIOR F--]5 GLASS LINING ❑ 6 UNLINED 5�/95 UNKNOWN E::]99 OTHER LINING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO D. CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC ❑PROTECTION 5 CATHODIC PROTECTION ❑ 91 NONE V95 UNKNOWN ❑ 99 OTHER E. SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED (YEAR)JAA ' /`1n 1/�/► 1 OVERFILL PREVENTION EQUIPMENT INSTALLED (YEAR) IV. PIPING INFORMATION CIRCLE A IF ABOVF GROUND OR U IF i1NnFAr.pr)I wn Rr1TH IF APPI Ir -API C A. SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A PGRAVITY A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND CORROSION PROTECTION A U A U A U 1 BARE STEEL 5 ALUMINUM 9 GALVANIZED STEEL A U A U A U 2 STAINLESS STEEL A U 6 CONCRETE A U 10 CATHODIC PROTECTION 3 POLYVINYL CHLORIDE (PVC) A U 4 FIBERGLASS PIPE 7 STEEL W/COATING A U 8 1009/ METHANOL COMPATIBLE W/FRP A695 UNKNOWN A U 99 OTHER D. LEAK DETECTION E 1 AUTOMATIC LINE LEAK DETECTOR D 2 LINE TIGHTNESS TESTING 3ER31 I IAL MONITORING OTHER V. TANK LEAK DETECTION F-7 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION 3 VADOZE MONITORING ❑ 4 AUTOMATIC TANK GAUGING❑ 5 GROUNDWATER MONITORING 6 TANK TESTING F-] F-]7 INTERSTITIAL MONITORING ❑ 91 NONE �5 UNKNOWN 99 OTHER VI. TANK CLOSURE INFORMATION 1. ES IMATED DATE LAST SED (MO1DAV/V$y , / 2. ESTIMATED QUANTITY OF SUBSTANCE REMAINING J TAI ORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, A APPLICANTS N E � (PRINTED 8 SI ) 1 M t — G � 1� LOCAL AGENCY USE ONLY THE STATE I.D. NUMBER IS C MPOSED OF THE1 3. WAS TANK FILLED WITH LONS INERT MATERIAL? YES NO S F M,Y KYOLEDGE, IS TRUE AND CORRECT DATE a -t it A4 R NUMBERS BELOW COUNTY # JURISDICTION # FACILITY # TANK # STATE I.D.# M 12131' 60 bff PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION - FORM A, UNLESS A CURRENT FORM A HAS BEEN FILED. FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS FORMS (12-91) poo � FOROW-R6 0d�