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• • STATE OF CALIFORNIA a STATE WATER RESOURCES CONTROL BOARDUNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT [ 4 AMENDED 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION E:] 7 PERMANENTLY CLOSED ONSITE ONE REM ❑ 2 INTERIM PERMIT -U " AMENDED PERMT ❑ 8 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: BEACON # 618' I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A OWNER'S TANK I.D.M 2 B. MANUFACTURED BY: M o DER N 1NSL- l NEICE] C. DATE INSTALLED(MO/DAYNEAR) 15 F 7 D. TANK CAPACITY IN GALLONS: 10000 II.TANK CONTENTS IFA-1 IS MARKED.COMPLETE ITEM C. A. E2e1 MOTOR VEHICLE FUEL [:j 4 OIL B. C, le REGULAR UNLEADED n`I� 3 DIESEL ❑ 8 AVIATION GAS ❑ 2 PETROLEUM E] 80 EMPTY ❑�1 PRODUCT ❑ Ib PREMIUM UNLEADED u 4 GASAHOL ❑ 7 METHANOL ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ tc MIDGRADE UNLEADED ❑ 5 JETFUEL ❑ 8 M85 ❑ 2 LEADED ❑ 99 OTHER(DESCRIBE IN TEND.BELOVO 0. IF(Al)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A S.# III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.B,AND C,AND ALL THAT APPLIES IN BOX D AND E A. TYPE OF 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 5 INTERNAL BLADDER SYSTEM ❑ 95 UNKNOWN SYSTEM ❑ 2 SINGLE WALL ❑ 4 SINGLE WALL IN A VAULT ❑ 99 OTHER B. TANK Ea" BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 8 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ B 100% METHANOL COMPATIBLE W/FRP (PfIRRMY TNII) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER C.INTERIOR ❑ 1 RUBBER UNED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING LINING OR ❑ 5 GLASS LINING [E�'8 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO— D.EXTERIOR ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP EEf"4 FIBERGLASS REINFORCED PLASTIC CORROSION PROTECTION ❑ 5 CATHODICPROTECTION ❑ 91 NONE ❑95 UNKNOWN ❑ 99 OTHER SPILL CONTAINMENT NSTALLEO(YEAR) OVERFILL P EVENTION EQUIPMENT INSTALLED(YEAR) E.SPILL AND OVERFILL,etc. DROP TUBE YES J NO_ STRIKER PLATE YES NO_ DISPENSER CONTAINMENT YES NO IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND,BOTH IF APPUCABLE A. SYSTEM TYPE A U 1 SUCTION A(U)2 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL A 2 DOUBLE WALL A U 3 UNED 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 v 4 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 8 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 lfiQP1°CAL U1%LEAN ❑2 UNE TKU M ED4 co9RB xreR9Tnw ELEcnwMc uxL ❑5 AUMMAIIC WARP ❑ s9 OTHER D aOR nnw MOMTORINo LEAK MTecmR vUIIX%I V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 RECO CILIATIONNUAL ORY ❑ 3 MONIITORING VAOZEI�4 GAUGINGC TANK ❑5 MONTORING�R ❑ 8 TESTING ❑ 7 MONITORING INTERSTITIAL ❑ 8 SIR ❑ 9 T%EKLGY A MANGAL ❑10 MONTTESHLY TANK NG ❑ 85 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) 1.ESTIMATED DATE LAST USED(MO/DAYNR) 2.ESTIMATED QUANTITY OF 3.WAS GE REMAINING GALLONS INERT MATERIAL 7 TANK FILLED WITH YES [:] NO❑ SUBSTANCE THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT TANK OWNER'S NAME DOUG (PRINTED A SIGNATURE) M A S 5APO FD(K U t-T P-A MA P, DATE *; -16-99 LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY# TANK M STATE I.D.# m 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. FORM C MUST BE COMPLETED FOR INSTALLATIONS.THIS FORM SHOULD BE ACCOMPANIED BY A PLOT PLAN. FILE THIFM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUNORAGE TANK REGULATIONS FORM B (B-BS)