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• 5cuaces STATE OF CALIFORNIA • r �� / STATE WATER RESOURCES CONTROL BOARD 3t_ ter; UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B a \ - COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSE N ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE [:?8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: �(� 2 STAINLESS STEEL L✓I'IS dh GAJ C. MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM . 1 HIVs umatl mir I IVIV COMPLETE ALL ITEMS -- SPECIFY IF UNKNOWN A. OWNER'S TANK 1. D. # C B. MANUFACTURED BY: yr � C. DATE INSTALLED (MO/DAY/YEAR) V N Ic D. TANK CAPACITY IN GALLONS: -7 v( V ILTANKCONTENTS IFA-11SMARKFf1 COMPI FTFITFMC A. 1 MOTOR VEHICLE FUEL 4 OIL B. C. ❑ to REGULAR3 DIESEL UNLEADEDL]6 AVIATION GAS ❑ 2 PETROLEUM F7 80 EMPTY 1 PRODUCT ❑ 4 GASAHOL ❑ ❑ 7 METHANOL ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE F—]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. #: 111- TANK CONSTRUCTION MARK nNF ITFM ONI YIN ROXFR A R aNn r aNn AI I TWAT APCI ICC IAI ally n nun C 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 ❑ 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 [�NKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED F—]2 ALKYD LINING F—]3 EPDXY LINING F—]4 PHENOLIC LINING C. INTERIOR LINING F—]5 GLASS LINING F—]9 6 UNLINED E 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 KNOWN ❑ 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 UNDFRGRnImn RnTU IF APPI If.ARIC A. SYSTEM TYPE A U F. 1 SUCTION AP 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 U 7 STEEL W/COATING A U U 5 UNKNOWN A U 4 FIBERGLASS PIPE 8 100% METHANOL COMPATIBLE W/FRP 99 OTHER D. LEAK DETECTION ❑ 1 AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING 3 INTERSTITIAL MONITORING ❑ 99 OTHER V. TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VADOZE MONITORING ❑ 4 AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORINC ❑ 6 TANK TESTING ❑ 7 INTERSTITIAL MONITORING ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER VI. TANK CLOSURE INFORMATION 1. ESTIMATED DATE LAST USED (MO/DAY/Y ) 2. ESTIMATED QUANTITY OF3. WAS TANK FILLED WITH YES NO ✓ SUBSTANCE REMAINING � GALLONS INERTMATERIAL? ❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANT'S NAME DATE (PRINTED 8 SIGNATURE) LOCAL AGENCY USE ONLY THE STATE I.D. NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY # JURISDICTION # FACILITY # TANK # STATE I. D.# 2 O 1 7b I/] PERMIT 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. 0 0 a