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STATEOFCAUFORMA STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B CO LETE A SEPARATE FORM FOR EACH TANK SYSTEM — % MARK ONLY ❑ 1 NEW PERMIT ONE ITEM F72 INTERIM PERMIT F]4 'SEN EWAL PERMIT AMENDED PERMIT ❑ 5 CHANGE OF INFORMATION❑ ❑ 6 TEMPORARY TANK CLOSURE 7 PERMANENTLY CL ITE ❑ 6 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: 5106 (� Ci�1 PRODUCT I. TANK DESCRIPTION COMPLETE ALL ITEMS - SPECIFY IF UNKNOWN ❑ 7 METHANOL 2 STAINLESS STEEL A. OWNER'S TANK I. D. i E::]4 OIL — % B. MANUFACTURED BY: 4k I/ 'W /V / C. DATE INSTALLED(MO/DAY/YEAR) /976 ❑ 6 AVIATION GAS D. TANK CAPACITY IN GALLONS: 14401 II_ TANK COMITENTS IFA -1 IS MARKED. COMPLETE ITEM C. I A 1 MOTOR VEHICLE FUEL E::]4 OIL B. ❑ 95 UNKNOWN C. 1a REGULAR I� 3 DIESEL ❑ 6 AVIATION GAS ❑ 2 PETROLEUM ❑ BO EMPTY Ezrl BARE STEEL Ci�1 PRODUCT LEADED L�Ji ❑ 1b PUNREMIUEO 4 GASAHOL ❑ 7 METHANOL 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE (PVC) A U 4 FIBERGLASS PIPE n`�j 5 JET FUEL ❑ 6 POLYVINYL CHLORIDE ❑ 3 CHEMICALPRODUCT E:]95 UNKNOWN (PrimaryTank) E]2 WASTE ❑ 2 LEADED u 99 OTHER (DESCRIBE IN ITEM D. BELOW) D. IF (A.1) IS NOT MARKED. ENTER NAME OF SUBSTANCE STORED S /i/ �7 C. A. S. i s L]4 PHENOLIC LINING III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN ROXESA.R. AND C. AND ALL THAT APPLIES IN BOX O ANDF A. TYPE OF ❑ DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM LV 2 INGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER 2 DOUBLE WALL Ezrl BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEELCLAD W/FIBERGLASS REINFORCED PLASTIC B. TANK 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE (PVC) A U 4 FIBERGLASS PIPE MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP (PrimaryTank) ❑ 9 BRONZE El10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER A U 95 UNKNOWN ❑ 1 RUBBER LINED ❑ 2 ALKYD LWW ❑G EPDXY LINING L]4 PHENOLIC LINING C. INTERIOR ❑ 5 GLASS LINING ❑ 6 UNLINED 95 UNKNO ❑ 99 OTHER LINING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO_ I(/Y�AnypZ/'TYi D. CORROSION r71 POLYETHYLENE WRAP ❑ 2 ATING F-13 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION [:]5 CATHODIC PROTECTION 1 NONE ❑ 95 UNKNOWN ❑ 99 OTHER E. SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED (YEAR) OVERFILL PREVENTION EOUIPMENT INSTALLED (YEAR) IV. PIPING INFORMATION CIRCLE A IFABOVEGROUNDOR U IF UNDERGROUND. BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION A U PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A 0 SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND A BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE (PVC) A U 4 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL Wl COATING A U 8 100% METHANOL COMPATIBLE W/FRP PROTECTION A U GALVANIZED STEEL A U 10 CATHOD PROTECTION A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION 1 AUTOMATIC LINE LEAK DETECTOR 2 LINE TIGHTNESS TESTING ❑ ❑ 99 OTHER MONRORING '. I ANN LEAN UC 1 Cl. I ION (N/��A ❑ 6 TANUAL K TESTING ❑ 7 INTERSTTIITAL MONITORING RECONCILIATION O 91VNO ZE MONITORING ❑ B5 AUTOMATIC NKNOWN Ta ✓A ❑ 99 GOTMER WATER MONITORING 1. ESTIMATED DATE LAST USED (MOIDAYNR) 2. ESTIMATED OUANTTY 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 OATS (PRIMED A SIGNATURE) LOCAL AGENCY USE ONLY THE STATE I.D. NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COL # JURISDICTION # -F�ACILITY#�- STATE 134m E : L�ZJ - PERMIT NUMBER I PERMIT APPROVED BY/DATE IPE 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