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7. Pf gU WPCs C^ ' , STATE OF CALIFORNIA & STATE WATER RESOURCES CONTROL BOARDc l UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B Io �4 iFon N,� COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ONSITE 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED ! owl, , DBA OR FACILITY NAME WHERE TANK IS INSTALLED: I. TANK DESCRIPTION COMPLETE ALL ITEMS -- SPECIFY IF UNKNOWN - B. MANUFACTURED BY: /YEAR) � D. TANK CAPACITY IN GALLONS: A. OWNER'S TANK I. D. # mrd i�fq C. DATE INSTALLED (MO/DAY 1 PRODUCT ❑ tb PREMIUM ❑ 4 GASAHOL ❑ 7 METHANOL UNLEADED ET L(DESCRIBE ❑ 3 CHEMICALPRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE 2 LEADED 99JOTHER iN ITEM D. BELOW) D. IF (A.1) IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C. A. S. A ❑ 2 STAINLESS STEEL 3 FIBERGLASS ❑ 4 STEEL CLAD W/ FIBERGLASS REINFORCED PLASTIC MATERIAL MARK ONLY ❑ 6 POLYVINYL CHLORIDE ONE ITEM 7. Pf gU WPCs C^ ' , STATE OF CALIFORNIA & STATE WATER RESOURCES CONTROL BOARDc l UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B Io �4 iFon N,� COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ONSITE 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED ! owl, , DBA OR FACILITY NAME WHERE TANK IS INSTALLED: I. TANK DESCRIPTION COMPLETE ALL ITEMS -- SPECIFY IF UNKNOWN - B. MANUFACTURED BY: /YEAR) � D. TANK CAPACITY IN GALLONS: A. OWNER'S TANK I. D. # g- _ laREGULAR C. ❑ ❑ 6 AVIATION GAS UNLEAR 3 DIESEL C. DATE INSTALLED (MO/DAY 1 PRODUCT ❑ tb PREMIUM ❑ 4 GASAHOL ❑ 7 METHANOL UNLEADED ET L(DESCRIBE ILTANKCONTENTS IFA -1 IS MARKED. COMPLETE ITEM C. IC - ❑ A. .��.I 1 MOTOR VEHICLE FUEL 4 OIL g- _ laREGULAR C. ❑ ❑ 6 AVIATION GAS UNLEAR 3 DIESEL 2 PETROLEUM ❑ 80 EMPTY 1 PRODUCT ❑ tb PREMIUM ❑ 4 GASAHOL ❑ 7 METHANOL UNLEADED ET L(DESCRIBE ❑ 3 CHEMICALPRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE 2 LEADED 99JOTHER iN ITEM D. BELOW) D. IF (A.1) IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C. A. S. A Ill. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A, B, AND C, AND ALL THAT APPLIES IN BOX D AND E /FJK�Y L�O[t r CiFCr,- i 4"` 3 E �C A. TYPE OF 1 DOUBLE WALL 3 SINGLE WALL WITH EXTERIOR LINER 95 UNKNOWN SYSTEM ❑ 2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTEDTANK) ❑ 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 7 ALUMINUM ❑ 8 100°/ METHANOL COMPATIBLE W/FRP (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL � 95 UNKNOWN 99 OTHER PROTECTION ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING C. INTERIOR ❑ 5 GLASS LINING 6 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER LINING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES NO D. CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING O 3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION � 91 NONE 95 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 t A. SYSTEM TYPE A U 1 SUCTION A , 12 PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL U DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U $9 OTHER C. MATERIAL AND A U 1 BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE (PVC)f V )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 INTERSTITIAL TESTING ❑ 3 ❑ 99 OTHER MONITORING VI. TANK CLOSURE INFORMATION 1. ESTIMATED DATE LAST USED (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 S SIGNATURE) - LOCAL AGENCY USE ONLY THE STATE I.D. NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY # JURISDICTION # FACILITY # TANK # STATE I.D,# m 1 PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE " 1` '"r /T qj THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION - FORM A, UNLESS A CURRENT FORM A HAS BEEN FILED. FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS ' FORM B (12-91) • • FOR00346•R6