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STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B UUMPLtI t A StPAHATt FOHM FOR E'PH TANK SYSTEM MARK'ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERM ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 6 TANK DBA OR FACILITY NAME WHERE TANK IS INSTALLED: n2C,p i jC>. OSL4 $4 /!pl ?r L TANK DFSCRIPTION (ntd01 CTC Al I ITC\AQ - QOCnlCV IC I IAI lAI/l1AA I l b• C•l�,. tih N�� n \ /A A. OWNER'S TANK I. D. * L4_ V �L.. 1p B. MANUFACTURED BY: V 1.4 Vji,-lotal#�j ❑ I REGULARDIESEL I=6 AVIATION GAS ❑ C. DATE INSTALLED (MO/DAYNEAR) GS! .- /TOCP I D. TANK CAPACITY IN GALLONS: &I cow IL TANKCONTFNTS tFA_7LQmikiRwFnrnt,APtCTC ITMAr A. [j�1 MOTOR VEHICLE FUEL ❑ 4 OIL B.C• ❑ I REGULARDIESEL I=6 AVIATION GAS ❑ ❑ 2 PETROLEUM (❑ 80 EMPTY li 1 PRODUCT � ❑ 'b PREMIUMUNLEADE❑ 5 JET FUEL L- T METHANOL E?3 ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED u 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 mikmw nNG ITCM rw v IRI OnYCC A 0 Whin t AAIn Al I YUAr A-1 ,ten -- n .— A. TYPE OF ❑ 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM [�J'2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER B. TANK [J -1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/ FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 1W16 METHANOL COMPATIBLE W/FRP (PrimaryTank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER 6 CONCRETE A U ❑ 1 RUBBER LINED ❑ 2 ALKYO LINING 3 EPDXY LINING ❑ 4 PHENOLIC LINING C. INTERIOR LINING ❑ 5 GLASS LINING [;?"6 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER D. LEAK DETECTION IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES _ NO_ DETECTOR Ej�-1 LINE TIGHTNESS TESTING 3 INTERSTITIAL D. CORROSION ❑ 1 POLYETHYLENE WRAP 2 COATING ❑ 3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE Cy�J5 UNKNOWN ❑ 99 OTHER E. SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED (YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED (YEAR) IV. PIPING INFORMATION CIRCLE 0 IF ARMP n pev lNn nm II ICI WnCOf 0n11RIn anT IC Ao.. In Aa1 A. SYSTEM TYPE A U I SUCTION p 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 A D 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 WiFRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION L rJ ' AUTOMATIC LINE LEAK DETECTOR Ej�-1 LINE TIGHTNESS TESTING 3 INTERSTITIAL r-1 99 OTHER E MONITORING V. TANK LEAK DETECTION [=? ll 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 a 99 OTHER VI. TANK CLOSURE INFORMATION 1. ESTIMATED DATE LAST USED (MO/OAYNR) I 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 WT OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANTS NAME DATE (PRINTED & SIGNATURE) A Z-Z(•4Z LOCAL AGENCY USE ONLY THE STATE I.D. NUMBER IS COMPOSED OF THE FOtfR NUMBERS BELOW COUNTY # JURISDICTION # FACILITY # TANK # STATE I.D. �m = 'ERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE FORM B (7-91) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION - FORM A, UNLESS A CURRENT FORM A HAS BEEN FILED. FOR00348-R5 S j�