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ro� ',, STATE OF CALIFORNIA . s • STATE WATER RESOURCES CONTROL BOARD i4 UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B COMPLETE A SEPARATE FORM FOR E TANK SYSTEM. MARK ONLY 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSEDSITE ONE REM 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT E]6 TEMPORARY TANK CLOSURE ❑ 9 TANK REMOVED 07 1 DBA OR FACILITY NAME WHERE TANK IS INSTALLED: Covin �S `Q� I. TANK DESCRIPTION COMPLETE ALL ITEMS - SPECIFY IF UNKNOWN A. OWNER'S TANK I. D. a M Z 3 DOI 3 S. MANUFACTURED BY: r Vff C� J r C. DATE INSTALLED (MO/DAYNEAR) 5-/7-(/ y7 D. TANK CAPACITY IN GALLONS: II_ TANK CONTENTS IF: A-11SMARKED. COMPLETE ITEM C- A(� 1 MOTOR VEHICLE FUEL ❑ 4 OIL Y�'�4 8. C.❑ 1a REGULAR15 3 DIESEL 6 AVIATION GAS Ll ❑ 2 PETROLEUM E]80 EMPTY 1 PRODUCT GAS OL ❑ 1bU N E DEIUM ❑ 5 JET FUEL ❑ 7 METHANOL ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED ❑ 99 OTHER (DESCRIBE IN ITEM D. 13ELOM D. IF (A.1) IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C. A. S. s: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES k13.AND C. AND ALL THAT APPI IFS IN ROX D ANDF 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 A U F—]1 BARE STEEL ❑ 2 STAINLESS STEEL � 3 FIBERGLASS 4 STEEL CLAD'W/ FIBERGLASS REINFORCED PLASTIC B. TANK 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 A U ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING C. INTERIOR ❑ 5 GLASS LINING® 6 UNLINED E-195 UNKNOWN 99 OTHER LINING 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION IS LINING MATERIAL COMPATIBLE WITH 10D% METHANO ? YES_ NO— NTERSTITLAL MONITORING D. CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 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) 2 7 OVERFILL PREVENTION EQUIPMENT INSTALLED (YEAR) 2-J 7 IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND. BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION AU 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL A(o 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND A U 1 BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE (PVC)A Co 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 TESTING 3 NTERSTITLAL MONITORING ❑ 99 OTHER V. TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VADOZE MONITORING � 4 AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING ❑ 6 TANK TESTING � 7 INTERSTITIAL MONITORING E]91 NONE ❑ 95 UNKNOWN 1:399 OTHER 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 (PRINTED a SIGNATURE) LOCAL AGENCY USE ONLY THE STATE I.D. NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW STATE I.D.# COUNTY # JURISDICTION # FACILITY # TANK # PERMIT NUMBER PERMIT APPROVED BYIDATE PERMIT EXPIRATION DATE THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION • FORM A, UNLESS A CURRENT FORM A HAS BEEN FILED. FILE THIS FORM WITH"'- LOCAL AGENCY IMPLEMENTING THE UNDERGROUND ST^"1GE TANK REGULATIONS FORM B (1291) FORON4 "