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4✓ • � • SpURCES + STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B_a A. OWNER'S TANK I. D. # / K ptep� COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. C. DATE INSTALLED (MO/DAYNEAR) 19�. Y MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT IN 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: L.. FA C l L / 7- Z' 1. TANK DESCRIPTION COMPLETE ALL ITEMS - SPECIFY IF DNKNnwN ❑ 6 1009/ METHANOL COMPATIBLE W/FRP (Primary Tank) A. OWNER'S TANK I. D. # / K ptep� B. MANUFACTURED BY: ,efxe 5 C. DATE INSTALLED (MO/DAYNEAR) 19�. Y D. TANK CAPACITY IN GALLONS: ! 1-11000 II. TANK CONTENTS Ir: A.II.CMARI(CnrnMPIPTP ITCMr A. 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. fi7'i 1a REGULAR 6 AVIATION GAS C fL�J UNLEADED ❑ 3 DIESEL 2 PETROLEUM 80 EMPTY 1 PRODUCT ❑ 1b PREMIUM ❑ 4 GASAHOL 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. 41: 111. TANK CONSTRUCTION MARK nNF ITGM nNl V IN QnYF3 A D AAIn r &Rin Al I TUAT ADDI ILO ISI -n .- r 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 F__]1 BARE STEEL ❑ 2 STAINLESS STEEL b?l 3 FIBERGLASS El4 STEEL CLAD W/ FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 6 1009/ METHANOL COMPATIBLE W/FRP (Primary Tank) 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER ❑ 99 OTHER I RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING C. INTERIOR LINING F7 GLASS LINING � 6 UNLINED F-]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 x 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER E. SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED (YEAR) N ChCKOIA, OVERFILL PREVENTION EQUIPMENT INSTALLED (YEAR) rA KCTL.O pr, IV. PIPING INFORMATION CIRCLE A IF ARovE GRnt1Nn nR LI IF I wnCRr:Rnl min DnT. IC ADDI IrADI 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 0 7 STEEL W/ COATING A U A U 95 UNKNOWN A U 4 FIBERGLASS PIPE 8 100% METHANOL COMPATIBLE W/FRP 99 OTHER D. LEAK DETECTION Xl AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING 3 I t 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. ESTIM TE DATE LAST USED (MO/DAY/YR) 2. ESTIMATED QUANTITY OF 3. WAS TANK FILLED WITH YES ❑ NO SUBSTANCE REMAINING GALLONS INERT MATERIAL? TAFOR HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANTS NAME / A DAT ^ \A (PRINTED &SIGNATURE) ��G, k� �� ^ Q > \`U LOCAL AGENCY USE ONLY THE STATE I.D. NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW !/�l/ v COUNTY # JURISDICTION # FACILITY # 601.570 TANK # 00/ STATE I.D.# a I D PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE ;�j ol .10 FORM B (7-91) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION - FORM A, UNLESS A CURRENT FORM A HAS BEEN FILED —1 U�y —9 Gx� �F0348-RS ' � o�t/ �i r