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• • RCp STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B rJ; 1 UU t I t A StVAHAIt: NORM FOR EACH TANK SYSTEM. B. MARK ONLY ❑ 1 NEW PERMIT ONE ITEM ❑ 2 INTERIM PERMIT 3 RENEWAL PERMIT 4 AMENDED PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 6 TEMPORARY TANK CLOSURE ❑ 7 PERMANENTLY CLOSED ONSITE ❑ 6 TANK REMOVED, . DBA OR FACILITY NAME WHERE TANK IS INSTALLED: 2 ❑ 7/ ! , I Taw nPQrRIDTInM .. I... ... ... .__.._ ------ UNLEADED ❑ 2 LEADED ❑ A. OWNER'S TANK I. D. % ' I �., I B. MANUFACTURED BY: (,fin IC C. DATE INSTALLED(MO/DAYNEAR) I clgz D. TANK CAPACITY IN GALLONS: 10 II. IANK NTENTS IFA -11S MARKED, COMPLETE ITEM C. A. FV 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C. ll.REGUNLEULAR ❑ 3 DIESEL ❑ 6 AVIATION GAS ❑ 2 PETROLEUM ❑ 60 EMPTY 1 PRODUCT ❑ 1b PREMIUM ❑ 4 GASAHOL ❑ METHANOL 7 ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE UNLEADED ❑ 2 LEADED ❑ 5 JETFUEL ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 9 100% METHANOL COMPATIBLE W/FRP ❑ 99 OTHER (DESCRIBE IN ITEM Q BELOW) D. IF (A.1) IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED Vo L1 sing,. 1-1-92- C.A.S.%: ❑ 95 UNKNOWN III. IAINN I-LINJI HUU I ILJN AAGGI((UIC ITCH n�II Vl.lonv�c• n A. TYPE OF ❑ DOUBLE WALL `V V^V ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM V2 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 ❑ 9 100% METHANOL COMPATIBLE W/FRP (PrimaryTank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER 4 FIBERGLASS PIPE 6 100 a METHANOL COMPATIBLE WIFRP 99 OTHER 1 RUBBER LINED2 ❑ ALKYD LINING ❑ j EPDXY LINING ❑ 4 PHENOLIC LINING C. INTERIOR LININIS ❑ 5 GLASS LINING ❑ 6 UNLINED 141— 95 UNKNOW ❑ 99 OTHER LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES _ NO�� yI D. CORROSION ❑ 1 POLYETHYLENE WRAP ❑ -2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION �[ f91 NONE 1-195 UNKNOWN ❑ 99 OTHER E. SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED (YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED (YEAR) IV. rIYINU INrUKMA I IUN CIRCLE AIFARnvcrnnlwnnR 11 lellunvoronl urn DCTu le.eeo....� A. SYSTEM TYPE A U 1 SUCTION A IIU 2 PRESSUR A U 3 GRAVITY p U 99 OTHER B. CONSTRUCTION A & 1 SINGLE W A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND CORROSION PROTECTION A A U A U 1 BARE STEEL 5 ALUMINUM GALVANIZED STEEL A U A U A U 2 STAINLESS STEEL A U 6 CONCRETE A U 10 CATHOD PROTECTION 3 POLYVINYL CHLORIDE (PVCIA U 7 STEELW/COATING A U p U 95 UNKNOWN A U 4 FIBERGLASS PIPE 6 100 a METHANOL COMPATIBLE WIFRP 99 OTHER D. LEAK DETECTION Vi AUTOMATIC LINE LEAK DETECTOR 2 LINE TIGHTNESS TESTING ❑ 7 MONFORING ❑ 99 OTHER '. 1A14M LOAN VII CGI IUN ❑ 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VADOZE MONITORING 4 AUTOMATIC TANK G�UUG1yG ❑ 5 GROUND WATER MONITORING ❑ 6 TANK TESTING ❑ 7 INTERSTITIAL MONITORING ❑� 91 NONE ❑ 95 UNKNOWN 9P ❑ 99 OTHER VI. I ANK GLUSURE INFORMATION 1. ESTIMATED DATE LAST USED IMO/DAY/YR) 2. ESTIMATED QUANTITY OF 3. WAS TANK FILLED WITH YES ❑ NO ❑ SUBSTANCE REMAINING GALLONS INERT MATERIAL '+ THIS FORM HAS BEEN COMPLETED UNDER PENALTYOF PERJURY, AND TO THE BEST OF MY KNnwl cnnc IQ T011C AA/n rnogECT APPLICANTS NAME-------_-_� .MVV (PRINTED a SIGNATURE) DATE LUUAL AULN(;Y USE ONLY THE STATE I.D. NUMBER IS COMPOSED OFTHE FOUR NUMBERS BELOW STATE LD.# COUNTY # JURISDICTION # FACILITY # TANK # 1/ ® = 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 \1 B(,`