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tyoon e9 STATE OF CALIFORNIA t '°" S STATE WATER RESOURCES CONTROL BOARD 3 ; UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B w w u 6 o COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM, MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ON SIT ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE 8 TANK REMOVED �w DBA OR FACILITY NAME WHERE TANK IS INSTALLED: I. TANK DESCRIPTION COMPLETE ALL ITEMS -- SPECIFY IF UNKNOWN A. OWNER'S TANK I. D. # B. MANUFACTURED BY: C. DATE INSTALLED (MO/DAY/YEAR) D. TANK CAPACITY IN GALLONS: `, r II. TANK CONTENTS IFA.IISAAAPW;:r) r)UPICTCITrAAc A. y 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. 1a REGULAR DIESEL C. 3 ❑ 6 AVIATION GAS �14 ❑ 2 PETROLEUM ❑ 80 EMPTY Ever1 PRODUCT UNLEADED GASAHOL ❑ 7 METHANOL O lbPREMIUM ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE UNLEADED El 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. s: III. TANK CONSTRUCTION MARK nNF ITEM nNI Y IN nnYFB A n ANn n AAIn Al I TUAT ADDI ICQ III - 1 Alin C A. TYPE OF ❑ 1 DOUBLE WALL F—]3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM 2 SING WALL ❑ 4 SECONDARY CONTAINMENT (VAULTEDTANK) ❑ 99 OTHER B. TANK �, 1 BARES ,EEL ❑ 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 D. LEAK DETECTION ❑ 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 10 95 UNKNOWN F-199 OTHER I/ E. SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED (YEAR) I �1 (1G �( f • OVERFILL PREVENTION EQUIPMENT INSTALLED (YEAR) 1 �I I I J ✓{' j IV. PIPING INFORMATION CIRCLF A IF AROVF rAnUNn nR tl IG I wnFnnnnl wn PnTW Ir ADD IPA 01 C A. SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY 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 8 100% METHANOL COMPATIBLE W/FRP A (U- 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION ❑ 1 MONEITORINGAL O AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING ETT IN RS gg THER V. TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VADOZE MONITORING 4 AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORINC ❑ 6 TANK TESTING 7 INTERSTITIAL MONITORING ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER VI. TANK CLOSURE INFORMATION 1. ESTIMATED,DATE LAST USED (MO(DAYNR) I 2. ESTIMATED OUANTITY OF ' L Ii SUBSTANCE REMAINING THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO T APPLICANTS NAME (PRINTED A SIGNATUR f lFVo', *' LOCAL AGENCY USE ONLY THE STATE I.D. NUMBER IS COMPOSED OF THE FOUR NUM 3. WAS TANK FILLED WITH YES F - NO f GALLONS INERT MATERIAL? B S-fOF MY KN' LEDGE, IS TRUE AND CORRECT DATE I COUNTY # JURISDICTION # FACILITY # TANK # STATE 04❑- J -L-T-FJ 'ERMIT 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 RFFN FILFD FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS FORM B (12-91) .. F011003413 -R6 l k.