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- � J kI 0--o STATE OF CALIFORNIASTATE WATER RESOURCES CONTROL BOARDUNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM MARK ONLY ❑ 1 NEW PERMIT 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY C-C$SD Ov SITE ONE ITEM ❑ 2 INTERIM PERM,? A AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE B TANK REMCtFD DBAOR FACILITY NAME WHERE TANK IS N iLD: I. TANK DESCRIPTION COMPLEc IL:-VS- SPECIFY IF UNKNOWN A. OWNER'S TANK 1.0.1B. MANUFACTURED BY: VI1�/ �14 I . C. DATE INSTALLED(MOIDAYIIAII 'I D. TANK CAPACITY IN GALLONS: ILTANKCONTENTS IFA-1 ISMAR<F-- =='�ITEIA C. I MOTOR VEHICLE FUEL • OIL B. C. ❑ 18UNLEA ED -=GASAHOL -. REGULAR 6 AV,:TPJN GAS A k- EMPTY �'� 1 PRODUCT ❑ 1E PREMIUM - p L�-,;AVOL2 PETROLEUM UNLEADED ❑ .-❑ 3 CHEMICALPRODUCT r UNKNOWN ❑ 2 WASTE ❑ 2 LEADED ❑ E ry -4 D.BELOVYID. IF(A.1)IS NOT MARKED. ENTER NAVE o-S1 -ANCE STORED III. TANK CONSTRUCTION MARK O -JI ONLY IN BOXES A.B.AND C.AND ALLTHAT APPLIES M BOX D AND ❑ t DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN A. TYPE OF SYSTEM 123. 2 SINGLE WALL 4 SECONDARY CONTAINMENT (VAULTED TANK) 99 OTHER❑ 1 BARE STEEL J 2 STAINLESS STEEL --5K3 FIBERGLASS ❑ d STEEL CLAD W/FIBERGLASS RE'v„OED PLASTIC B. TANK ❑ 6 POLYVINYL CHLORIDE 0 LE W°R° MATERIAL F-1 s CONCRETE 7 ALUMINUM ❑ B 1METHANOL COMPATIB❑ ❑ (PrimaryTank) ❑ 9 BRONZE J 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ W OTHER ❑ 1 RUBBER LIKE: ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ < PHENOLIC LINING C.INTERIOR ❑ 5 GLASS LINING 6 UNLINED -1��95 UNKNOWN ❑ W OTHER UNING IS LINING MATERIAL CO, '3_E WITH 100•A METHANOL? YES_ NO— D.CORROSION ❑ I POLYETHYLE%= NSAJ 2 COATING �❑--�."3 VINYL WRAP ❑ A FIBERGLASS REINFORCED PLASti PROTECTION F--] 5 CATHODICPRO'{-Cv ❑ 91 NONE S UNKNOWN ❑ 99 OTHER E.SPILL AND OVERFILL SPILLCONTAN -%T:%S.ALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) ✓Gs-lf� IV.PIPING INFORMATION CIRC-cA:FABOVEGROUND ORUIFUNDERGROUND,BOTH IFAPPLICABLE A. SYSTEM TYPE A 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A U I SINGLE N'CL A U 2 DOUBLE WALL A U 3 LINED TRENCH 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 U 6 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEELWICOATING A U 6 100.6 METHANOL COY°ATIBLEW/FRP PROTECTION A U 9 GALVANI=S-EL A U 10 CATHODIC PROTECTION ALV95 UNKNOWN A U 99 OTHER D. LEAK DETECTION ❑ 1 AUTOMATY;LICELEAKDEETECTOR ❑ 2 LINE TIGHTNESS TESTING ❑ 5 MONITORING ❑99 OTHER V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 INVENTCRY RECONCILIATION ❑ 3 VADOZE MONITORING X AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING ❑ 6 TANK TESTING ❑ 7 INTERSTITIALMONITORING ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION 1.ESTIMATED DATE LAST USED MOIDAY/YR) 12.ESTIMATED OUAN71TY OF 3.WAS TANK FILLED WITH YES ❑ NO _ SUBSTANCE REMAINING GALLONS INERTMATERIAL? THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE ST OF M KNOWLEDGE, IS TRUE AND CORRECT APPLICANT'S NAME Y DAT E CY' IVR SGNATURt�4 Yrj, , CC t 1 T fv Fy S LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY X JURISDICTION p FACILITY# TANK=# STATE I.D.# m �m ❑� PERMIT NUMBER PERMIT APPROVED BY/OATE PERMIT EXPIRATION DATE THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPUCATION•FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS FOR9m BR9 FORMS (12 91) h¢�