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� STATE OF CALIFORNIA � �• STATE WATER RESOURCES CONTROL BOARD s ' UNDERGROUND STORAGE TANK PERMIT APPLICATION • FORM B '( ' ° ra COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ON ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 6 TANK REMOVED ' DBAOR FACILITY NAME WHERE TANK IS INSTALLED: MCAAae- 1. TANK DESCRIPTION COMPLETE ALL ITEMS-- SPECIFY IF UNKNOWN A. OWNER'S TANK I.D.# B. MANUFACTURED SY: a•1FTt r NNg'y-.. C. DATE INSTALLED IMO/DAYNEAR) D. TANK CAPACITY IN GALLONS:C3� Odo ILTANKCONTENTS IFA-11S MARKED,COMPLETE ITEMC. 11 A 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C Y� 1a REGULAR ❑ 3 DIESEL ❑ 6 AVIATION GAS �T UNLEADED ❑ 4 GASAHOL O 2 PETROLEUM ❑ 80 EMPTY PRODUCT ❑ 1DUN EAIDUM D ❑ 5 JET FUEL ❑ 7 METHANOL ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ^❑ 2 WASTE ❑ 2 LEADED ❑ 99 OTHER (DESCRIBE IN ITEM D. BELOW) D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S.4: 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 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS 4 STEELCLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 8 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 6 100% METHANOL COMPATIBLE W/FRP (PrimaryTank) ❑ 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 �6 UNLINED L:] 95 UNKNOWN ❑ 99 OTHER LINING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO D.CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP X4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 01 NONE O95 UNKNOWN O 99 OTHER E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR) M'a OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A�q SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL A 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND A U i BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) 4 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEELW/COATING A U 6 100% METH NOL CO-A MP. ATIBLEW/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A 99 OTHER 1!1[{L� D. LEAK DETECTION X 1 AUTOMATIC LINE LEAK DETECTOR X2 LINE TIGHTNESS TESTING ❑ 3 MONPORING ❑ 99 OTHER V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK�K 2 INVENTORY RECONCILIATION ❑ 3 VADOZE MONITORING >L4 AUTOMATIC TANK GAUGING ❑ 5 GROUNDWATER MONITORING ;A416 TANK TESTING gSL7 INTERSTITIAL MONITORING ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION 1.ESTIMATED DAT A USED(MO/DAY/YR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH J SUBSTANCE REMAININGUl GALLONS INERT MATERIAL? EB ❑ NO ❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO BEST F MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANTS NAME DAT (PRINTED A SIGNATVREI vY $ L• LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW 23 Istoen C 'TC OUNTY# JURISDICTION FACILITY TANK-9 -- - STATE I.D.# ail l p O 0 5 PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE (� THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. D FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS FORM B (/2-91) 1 141 l 4-1