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t gpUn .e STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD 3_ 4 UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B <�_ no id . COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ON SITF ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE 8 TANK REMOVED - f! DBA OR FACILITY NAME WHERE TANK IS INSTALLED: 1 I. TANK DESCRIPTION COMPLETE ALL ITEMS -- SPECIFY IF UNKNOWN A. OWNER'S TANK I. D. # )f B. MANUFACTURED BY: ky�0 W C.❑ la REGULAR ❑ 3 DIESEL n 6 AVIATION GAS C. DATE INSTALLED (MO/DAY%YEAR) '! / D. TANK CAPACITY IN GALLONS: �i I G�' I ILTANKCONTENTS IF: A-11SMARKFn CnMPI FTFITFMC /I 11`-CJK- .5 CJ( -,U A �l/1 MOTOR VEHICLE FUEL ❑ 4 OIL -YY B. C.❑ la REGULAR ❑ 3 DIESEL n 6 AVIATION GAS ❑ 2 PETROLEUM ❑ 80 EMPTY1 F PRODUCT ❑ 4 GASAHOL ❑ lbPREMIUM ❑ 5, JET FUEL ❑ 7 METHANOL ❑ 3 CHEMICAL PRODUCT F-195 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED ❑/gg OTHER (DESCRIBE IN ITEM D. SELOWI D. IF (A.1) IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C. A. S. # III. TANK CONSTRUCTION MARK nNF ITEM nMI V IM D()VC4 A D AMn C Anon AI I TUAT ADDI ICC iki -- Akln A. TYPE OF ❑ 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM E�Z 2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER B. TANK lz 1 BARE STEEL F-]2 STAINLESS STEEL F--]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 F-]1 RUBBER LINED ❑ 2 ALKYD LINING F-]3 EPDXY LINING ❑ 4 PHENOLIC LINING C. INTERIOR LINING [:7]5 GLASS LINING ❑ 6 UNLINED 12,95 UNKNOWN ❑ 99 OTHER IS LINING MATERIAL COMPATIBLE WITH 1009 METHANOL? YES NO D. CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE [�Ti)5 UNKNOWN ❑ 99 OTHER E. SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED (YEAR) ) L i OVERFILL PREVENTION EQUIPMENT INSTALLED (YEAR) IV. PIPING INFORMATION cIRCI F A IF ARnvF rRnl INn nR 11 IF I IMnCO(:DM Wn Qr)TW IC ADDI V`ADI C A. SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A ,'U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A(U.,l 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 1 A U 5 A U 9 BARE STEEL ALUMINUM 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 A f 95 UNKNOWN A U 4 FIBERGLASS PIPE 8 100% METHANOL COMPATIBLE W/FRP 99 OTHER D. LEAK DETECTION ❑ 1 AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING [-I 3 IN E STI AL MONITORING / �� g9 OTHER V. TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VADOZE MONITORING ❑ 4 AUTOMATIC TANK GAUGING ❑ 5 GROUNDWATER MONITORING ❑ 6 TANK TESTING ❑ 7 INTERSTITIAL MONITORING C] 91 NONE [2'95 UNKNOWN ❑ 99 OTHER VI. TANK CLOSURE INFORMATION 1. ESTIMATED DATE LAST USES (M`O DAY R) 2 STIMATED SUBSTANCEOREMAINING UANTITY OF` GALLONS 3. WASINERT MATERIAL TANK FILLED ?H YES E0 NO 1- THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND Tq T BEST OF Y K WLEDGE, IS TRUE AND CORRECT APPLICANTS NAME DATE (PRI TED $SIGNATURE`) � LOCAL AGENCY USE ONLY THE STATE I.D. NUMBER IS COMPOSED OF THE UR NUMBERS BELOW COUNTY # JURISDICTION # FACILITY # TANK # STATE I.D.# 3 ca I = 1 -.311 co ❑ 1 r 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 FORM B (12-91) FOR00346-R6