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a � 50URCps STATE OF CALIFORNIA Ar. •ti 9 STATE WATER RESOURCES CONTROL BOARD w� , UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM B A-0 a f.• o COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED , DBA OR FACILITY NAME WHERE TANK IS INSTALLED: /g/O E. 42-E L T&n G. 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: II.TANKCONTENTS IFA-1 IS MARKED,COMPLETE ITEM C. AlNr'1 MOTOR VEHICLE FUEL ❑ 4 OIL g, C to REGULAR ❑ 3 DIESEL UNLEADED ❑ 6 AVIATION GAS ❑ 2 PETROLEUM ❑ 80 EMPTY 1 PRODUCT ❑ lb PREMIUM ❑ 4 GASAHOL ❑ 7 METHANOL ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 UNLEADED LEADED ❑ 99 JOTHER ET L(DESCRIBE IN ITEM D. BELOW) D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S.# III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.B,AND C,AND ALL THAT APPLIES IN BOX D AND E 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 Q 7 ALUMINUM ❑ 8 100°/< METHANOL COMPATIBLE W/FRP (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL a 95 UNKNOWN a 99 OTHER ❑ 1 RUBBER LINED 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING C.INTERIOR ❑ 5 GLASS LININGy6 UNLINED F-] 95 UNKNOWN ❑ 99 OTHER LINING �`'� 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 X95 UNKNOWN ❑ 99 OTHER E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR) //��--�� OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) IV.PIPING INFORMATION CIRCLE A IFABOVEGROUNDOR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A&1 SUCTION A U 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 A 1 BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A U 4 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL W/COATING A U 8 100°/ METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION ❑ 1 AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING ❑ 3 TeRSTITIAL MONITORING ❑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 ❑ 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION 1.ESTIMATED DATE LAS SED(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&SIGNATURE) LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW r) COUNTY# JURISDICTION# FACILITY# g cq TANK# STATE I.D.# l j �� 1 rl L1 PERMITNUMBER PERMIT APPROVEDBY/DATE- PERMIT EXPIRATIOND�TEI THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. FILE THIS FORM WITH§LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS FORM B (12-91) y/� r, [ --- FOR0034&R6 / !- I