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STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B COMPLETE A SEPARATE FORM FOR MARK ONLY ❑I 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT DBA OR FACILITY NAME WHERE TANK IS INSTALLED: to r -C-0 I. TANK DESCRIPTION COMPLETE ALL ITEMS -- SPECIFY IF UNKNOWN E-- TANK SYSTEM. 5 CHANGE OF INFORMATION ❑ 7 PE 6 TEMPORARY TANK CLOSURE ❑ 8 TA o5L1a . //v/? kb Alli A. OWNER'S TANK I. D. # 2 _ U 14L_ 12 B. MANUFACTURED BY: C. DATE INSTALLED (MO/DAY/YEAR) Q S / _/�� D. TANK CAPACITY IN GALLONS: L 4 t 0Oo ILTANKCONTENTS IFA -1 IS MARKED. COMPLETE ITEM C. A E'- ' MOTOR VEHICLE FUEL ❑ 4 OIL B.C. ❑UNLEADED REGULAR 3 DIESEL ❑ 6 AVIATION GAS 4 GASAHOL 2 PETROLEUM ❑ 80 EMPTY 1 PRODUCT ❑ lb PREMIUM ❑ 7 METHANOL UNLEADED 5 JET FUEL 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ U 2 LEADED ❑ 99 OTHER (DESCRIBE IN ITEM D. BELOWI D. IF (A.1) IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C. A. S. #: 111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN ROXES A_ R_ AND C. AND ALL THAT APPI IFS IN ROX D AND F A. TYPE OF ❑ 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM E2"2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER B. TANK 7l 1 BARE STEEL ❑ 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 1 AUTOMATIC LINE LEAK DETECTOR LINE TIGHTNESS TESTING 3 A MONITORING ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING C. INTERIOR LINING ❑ 5 GLASS LINING ©16 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 �F5 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 APPLICABLE A. SYSTEM TYPE A U 1 SUCTION A(2)2 PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A(D 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 AG) 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 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 1 AUTOMATIC LINE LEAK DETECTOR LINE TIGHTNESS TESTING 3 A MONITORING ❑ 99 OTHER V. TANK LEAK DETECTION 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VADOZE MONITORING ❑ 4 AUTOMATIC TANK GAUGING 0 5 GROUND WATER MONITORING [:j;.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 SUBSTANCE REMAINING GALLONS INERT MATERIAL? YES ❑ NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANTS NAME DATE (PRINTEDof& SIGNATURE) `u � .� • � � LOCAL AGENCY USE ONLY THE STATE I.D. NUMBER IS COMPOSED OF THE FOUR NUwERS BELOW STATE I.D.# C`'_r ," COUNTY # JURISDICTION # FACILITY # TANK # 'ERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE f FORM B (7-91) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION • FORM A, UNLESS A CURRENT FORM A HAS BEEN FILED. FOROW48-R5 i 001 /4