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Ae <br /> .•. <br /> 0 5TATE OP CALIFORNIA 4 <br /> STATE WATER RESOURCES CONTROL BOARD w<< <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION-FORM B <br /> COMPLETE A SEPARATE FORM FOR H TANK SYSTEM. <br /> MARK'ONLY 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION Q 7 PERMAN Sc ON SI� . <br /> -,v <br /> ONE IT 2 INTERIM PERMIT a AMENDED PERMIT 8 TEMPORARY TANK CLOSURE Q 8 TAN E <br /> DBA OR FACILITY NAME WHERE TANK IS INSTALLED: AG.l.p I.10. OSN <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS-SPECIFY IF UNKNOWN <br /> A. OWNER'S TANK I.0.0 S I B. MANUFACTURED BY: <br /> C. DATE INSTALLED(MO/OAY/YEAR) QCT �� I 0. TANK CAPACITY IN GALLONS: SSO <br /> II.TANK CONTENTS IFA-1 IS MARKED.COMPLETEITEMC. <br /> to REGULAR <br /> A. i MOTOR VEHICLE FUEL 2f," OIL B. C• ❑ UNLEADED � 3 DIESEL J ; AVIATION GAS <br /> 2 PETROLEUM 80 EMPTY t PRODUCT lb PREMIUM s GASAI IOL —' <br /> UNLEADED 5 JETFUEL T .METHANOL <br /> Q 3 CHEMICAL PROOUCT 95 UNKNOWN =,,,<2 WASTE 2 LEADED =--99 OTHER (DESCRIBE IN ITEM 0. BELOW) <br /> 0. IF(A.1)IS NOT MARKED. ENTER NAME OF SUBSTANCE STORED L7S E O 1"2C'TOIQ oil C.A.S.0: <br /> $00la Co 1 <br /> III. TANK C 0 NSTR UCTIO N MARK ONE ITEM ONLY IN BOXES A.B.AND C.AND ALL THAT APPLIES IN BOX O AND E <br /> A. TYPE OF C 1 DOUBLE WALL 3 SINGLE WALL WITH EXTERIOR LINER 95 UNKNOWN <br /> SYSTEM �2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) 99 OTHER <br /> B. TANK 1 BARE STEEL 2 STAINLESS STEEL. 3 FIBERGLASS U It STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC <br /> MATERIAL Cj 5 CONCRETE 8 POLYVINYL CHLORIDE 7 ALUMINUM IL 100% METHANOL COMPATISLEW/FRP <br /> (PrimaryTank) 9 BRONZE 10 GALVANIZED STEEL 95 UNKNOWN 99 OTHER <br /> 1 RUBBERPHENOLIC <br /> BER LINED U 2 ALKYO LINING 3 EPDXY LINING a LINING <br /> C.INTERIOR '1 <br /> LINING 5 GLASS LINING �8 UNLINED 95 UNKNOWN 99 OTHER <br /> L_.J <br /> IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? YES_ NO_ <br /> D.CORROSION U 1 POLYETHYLENE WRAP {� 2 COATING = 3 VINYL WRAP a FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION 5 CATHODIC PROTECTION J 91 NONE 211.5 UNKNOWN N OTHER <br /> F SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) <br /> IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND.BOTH IFAPPLICA13LE <br /> A. SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A(l) 99 OTHER <br /> S. CONSTRUCTION A U 1 SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN AQ 99 OTHER <br /> C. MATERIAL AND A U I BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A U 4 FIBERGLASS PIPE <br /> CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL W/COATING A U 8 700% METHANOL COMPATIBLE W/FRP <br /> PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN <br /> AO99 OTHER 1�L0,�t <br /> D. LEAK DETECTION L7 1 AUTOMATIC LNE LEAK DE T ECTOR E] 2 LINE TIGHTNESS TESTING 3 uONRORCIG Ct�99 OTHER >s <br /> V.TANK LEAK DETECTION <br /> L.�l VISUAL CHECK 2 INVENTORY RECONCI ATION 3 VAOOZE MONITORING A AUTOMATIC TANK GAUGING 5 GROUND WATeR MONITORING <br /> r4-8 TANK TESTING = 7 INTERSTITIALMONiTORNG 91 NONE 95 UNKNOWN 99 OTHER <br /> VI.TANK CLOSURE INFORMATION <br /> 1.ESTIMATED DATE LAST USED(MO/DAY/YR) ` 7-ESTIMATED QUANTITY OF I 3.WAS TANK FILLED WITH YES NO I_ <br /> SUBSTANCE REMAINING GALLONS INERT MATERIAL? <br /> I HIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE. IS TRUE AND CORRECT <br /> APPLICANTS NAME DATE <br /> IPRINTEO&SIGNATURE) <br /> E� �Z Z•Zt•9L � <br /> LOCAL AGENCY USE ONLY THE STATE LD.NUMBER IS COMPO D OFTHE FOUR NUMBERS BELOW J <br /> COUNTY 9 JURISDICTION x FACILITY x TANK;t <br /> STATE I.D.-'� I ' �� ! i r IZ l z� io_5 <br /> PERMIT NUMBER i PERMIT APPROVED BY/DATE I PERMITEXPIRATION DATE t <br /> -ORM B (7-91) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION.FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. <br /> FOAOmt&A5 <br />