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STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD S UNDERGROUND STORAGE TANK PERMIT APPLICATION • FORM B �' o COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. `'r�o•�'' MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION O 7 PERMANENTLY CLOSED ON SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE fTif 8 TANK REMOVED WH DBA OR FACILITY NAME ERE TANK IS INSTALLED: {A,`( K�1 Q I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A. OWNER'S TANK I.O.# B. MANUFACTURED BY: C. DATE INSTALLED(MC/DAY/YEAR) �O ,M� D. TANK CAPACITY IN GALLONS: u(/V II.TANK CONTENTS IFA-1 IS MARKED,COMPLETE ITEM C. �} A. 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C. ❑ laREOULAR UNLEADED y�j 3 DIESEL ❑ 6 AVIATION GAS ❑ 2 PETROLEUM ❑ ea EMPTY ❑ 1 PRODUCT ❑ tb PREM IUM -__LLLJJJ 4 1ASAHOL ❑ 7 METHANOL ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE 2 LEADED ❑ 5 JET FUEL ❑ ❑ R9 OTHER (DESCRIBE IN ITEM D. BELOW) D. IF(A.1)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 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 B. TANK Ip 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP (PrimnyTmk) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING C.INTERIOR ❑ 5 GLASS LINING X17, a UNLINED ❑ LINING MJF ❑ 95 UNKNOWN 99 OTHER IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? YES_ ND_ 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) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION A)2 PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A 1 SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND A&I 1 RARE 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 STEELW/COATING A U 9 100% METHANOL COMPATIBLE W/FRP PROTECTION p U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION p U 95 UNKNOWN p U 99 OTHER D. LEAK DETECTION ❑ 1 AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING ❑ 3 MONITORING ❑ 99 OTHER C►vc 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 5'91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION 1.ESTIM D.�D9TE LAST USED(MO/DAY/YR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES NO ll�'l SUBSTANCE REPINING �GpLLONS INERTMATERIAL7 ❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF RJUFJY,AND TO THE BEST 4 MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANTS NAME �� L DATE IPFINTE96 APPLICANT'S AM EI GV1 LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER I MPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY# TANK# STATE I.D.# yff dlj� 'pti IlDh 7 PERMIT NUMBER PERMIT APPROVED BYIDATE PERMIT EXPIRATION DPRE THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORM A,UNLESS A CURRENT FORM A HA BEEN F ED. FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS FORM B (12-91) FORO¢M&R6 `/ \.m4I