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STATE OF CALIFORNIA SPUR .e P ft Cil STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B a�' ` u° I V ' PRODUCT o COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. ❑ 2 WASTE MARK ONLY ❑ 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMAN --]ONE LY CLOSED' ON S ITEM 2 INTERIM PERMIT 4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE 8 TANK F MOVED ` n l�-1 DBA OR FACILITY NAME WHERE TANK IS INSTALLED: I ��^ l vV ❑ 5 CONCRETE I. TANK DESCRIPTION COMPLETE ALL ITEMS -- SPECIFY IF UNKNOWN ❑ 7 ALUMINUM A. OWNER'S TANK I. D. # B. MANUFACTURED BY: h O ❑ 9 BRONZE C. DATE INSTALLED (MO/DAY/YEAR) O MW D. TANK CAPACITY IN GALLONS: ❑ 99 OTHER ❑ 1 RUBBER LINED II- TANK OONTFNTS ICA-11QUAGICCnrnMIDICTCI—k— ❑ 3 EPDXY LINING A. 1 MOTOR VEHICLE FUEL ❑ 4 OIL F72 PETROLEUM B. C. 5? aREGULAR UN EAD D �—� 3 DIESEL ❑ 6 AVIATION GAS U 4 GASAHOL F780 EMPTY I V ' PRODUCT ❑ ib PREMIUM ❑ 7 METHANOL ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE UNLEADED ❑ 5 JET FUEL ❑ 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 nNF 1TPM ONI V IN POYFR A a Anon r ANn Al I TUAT ADDI IEQ - — n Aran 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 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 ❑ 1 RUBBER LINED F--]2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING C. INTERIOR LINING F-]5 GLASS LINING ❑ 6 UNLINED 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 % UNKNOWN ❑ 99 OTHER E. SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED (YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED (YEAR) IV. PIPING INFORMATION clRclF o IFARnvFran.iNnnz II i�iiAln�Dr_Dn1IAIn DnTu ADD. A. SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE An GRAVITY A U 99 OTHER B. CONSTRUCTION A 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 A )�5 UNKNOWN A U 99 OTHER D. LEAK DETECTION ❑ 1 AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING 3 N E STI AL 99 OTHER MONITORING 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 re"*15 UNKNOWN ❑ 99 OTHER VI. TANK CLOSURE INFORMATION 1. E TIMA A E LAST US D (MO/DAV Y 2. ESTIMATED QUANTITY OF 3. WAS TANK FILLED WITH YES �NO L::]�� SUBSTANCE REMAINING GALLONS INERT MATERIAL? THIS ORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TOT OF MY GE, IS TRUE AND CORRECT APPLICANTS NAME , _ (PRINTED d SIGNATU I • l l� ^ �0 DATE \l LOCAL AGENCY USE ONLY THE STATE I.D. NUMBER IS COMP SED OF THE FO R NU ERS BELO COUNTY # JURISDICTION # FACILITY # TANK # STATE I.D.# 5A 12 rr to O I i r4 I Co 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. FORM B (12-91) FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS y �qjj 5 /�j�jFDR0034 B� R6 r% –