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/ • STATE OF CALIFORNIA • •`' �� ; q V STATE WATER RESOURCES CONTROL BOARD °� 1 6/11 UNDERGROUND STORAGE TANK PERMIT APPLICATION• FORM B W 4 'O •M/� p1 COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. °•,��o•�.' MARK ONLY ❑ i NEW PERMIT 3 RENEWAL PERMIT ONE ITEM ❑ 2 INTERIM PERMIT 5 CHANGE OF INFORMATION ] MANENTLY CLOSED ONSITE ❑ 4 AMENDED PERMIT ❑ 8 TEMPO RARV TANK CLOSURE B TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: v pe I. TANK DESCRIPTION COMPLETE ALL ITEMS-- SPECIFY IF UNKNOWN A. OWNER'S TANK I.D.# I B. MANUFACTURED BY: " 14 C. DATE INSTALLED(MO/DAV/YEAR) 1n IC D. TANK CAPACITY IN GALLONS: ILTANKCONTENTS IFA-11S MARKED,COMPLETE ITEM C. A. ❑ 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. FIREGULAR III�� ❑ 2 PETROLEUM 1 ❑ C. ❑ UNLEADED 3 DIESEL ❑ 6AVIATION GAS ❑ 60 EMPTY 1 PRODUCT ib PREMIUM u 4 GASAHOL ❑ 3 CHEMICAL PRODUCT UNKNOWN O 2 WASTE O 2 LEL_ C C ❑ 5 JET FUEL ❑ ] METHANOL D. IF .1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED ❑ 9g OTHER (DESCRIBE IN ITEM D. BELOW) C.A.S.A III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A,B.AND C.AND ALL THAT APPLIES IN BOX DANOE f(PrimaryTank) F t LE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER M ❑ ❑ 95 UNKNOWN WALL 4 SECONDARY CONTAINMENT K) ❑ (VAULTED TAN 99 OTHER STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W1 FIBERGLASS REINFORCED PLASTIC AL RETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ZE ❑ 10 GALVANIZED STEEL 95 UNKNOWN ❑ S 100% METHANOL COMPATIBLE W/FRP ❑ ❑ 99 OTHER ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING C.INTERIOR ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING LINING ❑ 5 GLASS LINING ❑ 6 UNLINED 5 UNKNOWN ❑ 99 OTHER IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO— D.CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL Wqqp ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION 1 NONE 95 UNKNOWN ❑ gg OTHER E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) IV.PIPING INFORMATION CIRCLE A IF A80VE GROUND OR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A RAVI7Y A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH LUNKNON A U 99 OTHER C. MATERIAL AND A U 1 BARE STEEL p U 2 STAINLESS STEEL p U 3 POLYVINYL CHLORIDE(PVC)ABERGLASS PIPECORROSION AU 5 ALUMINUM A U 2 CONCRETEPROTECTION I U 7 STEE W/COATING A0% METHANOL COMPATIBLE W/FRPA U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION UNKNOWND. LEAK DETECTION ❑ 1 AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING ATHERV.TANK LEAK DETECTION 3 MONITORIN9a OTHER ❑❑ 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VADOZE 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/DAYIVR) 2.ESTIMATED QUANTITY OF SUBSTANCE REMAINING (/JJ-� 3.WAS TANK FILLED WITH L�CALLONS INERT 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 (PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OFTHE FOUR NUMBERS BELOW FAC STATE I.D.# COUNTY# JURISDICTION# n�11� � � S QTANK# PERMIT NUMBER PERMIT APPROVED BV/DATE z —I PERMIT EXPIRATION DATE2�� THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. FORM B (1e-91) FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS 0 0 FORD g R6