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P5o-- C C STATE OF CALIFORNIA Ae STATE WATER RESOURCES CONTROL BOARD 3 UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B �� ;� 'a° 0 COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSE SI ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE 8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: itU / Oft VIrLG IC MLL II CMJ-- OrCkdrT IY UNIINUWN A. OWNER'S TANK I. D. A C. DATE INSTALLED (MO/DAY/YEAR) l S II. TANKCONTFNTS IFA.1lQKAARKCnenAAOICTCITCAAc B. MANUFACTURED BY: r 1 1 {o I A I / D. TANK CAPACITY IN GALLONS: A. 1 MOTOR VEHICLE FUEL ❑ 4 OIL g, to REGULAR 3 DIESEL C, 6 AVIATION GAS UNLEADED ❑ ❑ 2 PETROLEUM ❑ 80 EMPTY 1 PRODUCT 4 GASAHOL 1b PREMIUM ❑ ❑ ❑ 7 METHANOL UNLEADED ❑ 5 JET FUEL ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED [;�J�99 OTHER (DESCRIBE IN ITEM D. BELOW) D. IF (A.1) IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C. A. S. e III. TANK CONSTRUCTION MARK ONF ITEM nNi V IN RnYFS AM ANn c AAIn AI I TWAT ADDI ICO Ira O— n Aran c A. TYPE OF ❑ 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� 4u 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/ FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 6 100% METHANOL COMPATIBLE W/FRP (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER AUTOMATIC LINE LEAK DETECTOR[:]2 LINE TIGHTNESS TESTING 3 ❑ F-]1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING C. INTERIOR LINING F—]5 GLASS LINING E:]6 UNLINED 2r 95 UNKNOWN ❑ 99 OTHER IS LINING MATERIAL COMPATIBLE WITH 100/ METHANOL? YES_ NO_ D. CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE >C2195 UNKNOWN ❑ 99 OTHER E. SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED (YEAR)v"6—aq OVERFILL PREVENTION EQUIPMENT INSTALLED (YEAR)—&M—WA) IV. PIPING INFORMATION CIRCLE A IF AROVF GROUNn nR U IF IJNnFR(;RnI imn Q0TW IC A001 Iced C A. SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION AE) 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 7 STEEL W/ COATING A U 0 95 UNKNOWN A U 4 FIBERGLASS PIPE 8 1009/6 METHANOL COMPATIBLE W/FRP 99 OTHER D. LEAK DETECTION 1 AUTOMATIC LINE LEAK DETECTOR[:]2 LINE TIGHTNESS TESTING 3 ❑ INTERSTITIAL MONITORING I tv 99 OTHER V. TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VADOZE MONITORING ❑ 4 AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING ❑ 6 TANK TESTING ❑ 7 INTERSTITIAL MONITORING ❑ 91 NONE Lam"" UNKNOWN ❑ 99 OTHER VI. TANK CLOSURE INFORMATION 1. ESTIMATED DATE LAST USED (MO/DAY/Y ) 2. ESTIMATED QUANTITY OF 3. WAS TANK FILLED WITH YES NOfDx ❑ i SUBSTANCE REMAINING GALLONS INERT MATERIAL ? THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, Ahlb TO THE OF N W GE, IS TRUE AND CORRECT APPLICANTS NAME luk/ Z' (PRINTED A SIGNATURE) (1 _ ( DATE __ LOCAL AGENCY USE ONLY THE STATE I.D. NUMBER IS COMPOSED OF THE FOUR NUMBERS BEL 7(l/�_�) COUNTY # JURISDICTION # FACILITY # TANK # STATE I.D.# ® 2 1 � to v O 'ERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION • FORM A. UNI FSS A CLIRRFNT FnRM a Has RFFN FN Fn FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS FORM B (12-91) FpR0054&R6