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• • OU. E STATE OF CALIFORNIA "° STATE WATER RESOURCES CONTROL BOARD i° UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B �� ye a y.s ,..1. o G COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. 04¢Oe"�� MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ONSITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ B TANK REMOVED �Z DBA OR FACILITY NAME WHERE TANK IS INSTALLED: �O/ 'w GOf�2 iQ.l>� I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A. OWNER'S TANK I.D.# 05 1 B. MANUFACTURED BY: G C. DATE INSTALLED(MO/DAYNEAR) D. TANK CAPACITY IN GALLONS: r> LD ll.TANK C ENTS IFA-11SMARKED,COMPLETE ITEM C. A. Z1 MOTOR VEHICLE FUEL ❑ 4 OILB. C. ❑ la EGULANUEADED 3 DIESEL ❑ 6 AVIATIONGAS El PETROLEUM ❑ SO EMPTY 1 PRODUCT 1b PREMIUM 4 GASOHOL ❑ 7 METHANOL [_] 3 CHEMICAL PRODUCT 95 UNKNOWN 2 WASTE❑ ❑ ❑ UNLEADED O 99 J OTHER (DESCRIBEIN ITEM D. BELOW) 2 LEADED D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S.# III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXESA,B,AND C.AND ALLTHAT APPLIES IN BOXD AND A. TYPE OF ,❑ 11 DOUBLE WALL F-13 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM I 2 INGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER S. TANK 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM B 100% METHANOL COMPATIBLE W/FRP (Primary Tank) 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ -99 OTHER ❑ 1 RUBBER LINEDn Z�ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING C.INTERIOR F-] 5 GLASS LINING 6 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER LINING IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? YES_ NO- D.CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE d5 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 PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED 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 U 4 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEFyW/COATING A U 6 100% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION Alu UNKNOWN A U 99 OTHER D. LEAK DETECTION ❑ 1 AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING ❑ 3 MONrT'oT L—] 99 OTHER V.TANK LEAK DETECTION ❑ L CHECK 2 INVENTORY RECONCILIATION ❑ 3 VAD07E MONITORING ❑ 4 AUTOMATIC TANK GAUGING ❑ 5 GROUNDWATER MONITORING 6 TANK TESTING ❑ 7 INTERSTITIAL MONITORING ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION 1.ESTIMATED DATE LAST USED(MO/DAY/YR) 2.ESTIMATED QUANTITY OF 3,WAS TANK FILLED WITH SUBSTANCE REMAINING GALLONS IN MATERIAL? YES ❑ NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANTS NAME DATE (PRINTED a SIGNATURE) LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY# TANK# STATE I.D.# eor � PERMITNUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE s e /, f� FORMS (7.91) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. / • 1//'�D7AV/ / Jgpp B-RS