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r' „w r , STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD W UNDERGROUND STORAGE TANK PERMIT APPLICATION • FORM B COMPLETE A SEPARATE FORM FOR EACH K SYSTEM. MARK ONLY ❑ 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ONSITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: l -:� Is Qc, ' loo S ke- I) I. TANK DESCRIPTION COMPLETE ALL ITEMS •- SPECIFY IF UNKNOWN A. OWNER'S TANK I. D. # c J B. MANUFACTURED BY: C. DATE INSTALLED (MO/DAYNEAR) ' cl ( D. TANK CAPACITY IN GALLONS: Oi ILTANKCONTENTS IFA -1 IRMARKFD COMPI FTPITEMC A. OTOVEHICLE FUEL 4 OIL B. C. ❑ 1. REG LAR 3 DIESEL ❑ 6 AVIATION GAS ❑ 95 UNKNOWN SYSTEM ❑ 4 GASAHOL 2 PETROLEUM ❑ 80 EMPTY ��PRODUCT ❑ lbPREMIIUM❑ 5 JET FUEL ❑ 7 METHANOL UNLEADED ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 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 ONF ITFM ONI Y IN ROXFS A R AND C AND Al I THAT APPI IFR IN ROY O AND F A. TYPE OF ❑-1 DOUBLE WALL F--]3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM [ 2 SINGLE WALL /j / ❑ 4 SECONDARY CONTAINMENT (VAULTEDTANK) ❑ 99 OTHER B. TANK E?` -1 -BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/ FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 1009/6 METHANOL COMPATIBLE W/FRP (PrimaryTank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL L;;;95 -UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING C. INTERIOR ❑ 5 GLASS LINING ❑ 6 UNLINED LJ UNKNOWN ❑ 99 OTHER LINING / - IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES ✓ NO D. CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 33 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION [7]5 CATHODIC PROTECTION F-]91 NONE �'95 UNKNOWN ❑ 99 OTHER E. SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED (YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED (YEAR) IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND BOTH IF APPI ICARI F A. SYSTEM TYPE A U 1 SUCTION A& 2 PRESSURE A U 3 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 2 STAINLESS STEEL A U A U 6 CONCRETE A U A U 10 CATHODIC PROTECTION 3 POLYVINYL CHLORIDE (PVC) A U 7 STEEL W/COATING A U A U 95 UNKNOWN A U 4 FIBERGLASS PIPE 8 1009/6 METHANOL COMPATIBLE W/FRP 99 OTHER D. LEAK DETECTION ❑ 1 AUTOMATIC LINE LEAK DETECTOR2 LINE TIGHTNESS TESTING ❑ 3 MONITORINGINTERSTITIAL ❑ 99 OTHER i/ T�\11/ � rel/ f1rTrAT1f1\1 V. 1PAINIM LCHI1% VC1 CliI IV1V ❑ 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 ❑ 95 UNKNOWN ❑ 99 OTHER VI. TANK CLOSURE INFORMATION 1. ESTIMATED DATE LAST USED (MO/DAY/YR) 2. ESTIMATED QUANTITY OF 3. WAS TANK FILLED WITH YES ❑NO SUBSTANCE REMAINING GALLONS INERT MATERIAL? THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANTS NAME DATE (PRINTED A SIGNATURE) LOCAL AGENCY USE ONLY THE STATE I.D. NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY # JURISDICTION # FACILITY # TANK # STATE I.D.# � = 6 b _)cr-9 PERMITNUMBER PERMIT APPROVED BY/DATE MITZEEXXP.IRgTTIION ATE 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) ? 'f G'v FOR0034M6