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r i STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD #-• UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B i1r c�4rgn�'r COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED ON SITE [D8;A0R;FLAC;lL11Y ❑ NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ B TANK REMOVED r NAME WHERE TANK IS INSTALLED: Y"S S I. TANK DESCRIPTION COMPLETE ALL ITEMS-- SPECIFY IF UNKNOWN B. MANUFACTURED BY: 6'A;7-- %/�1,4 S c o A. OWNER'S TANK !.D.0 �7 - C. DATE INSTALLED(MO1pAYNEAR) / ��[� p. TANK CAPACITY IN GALLONS: /a �-�L.l0 t' I—C II.TANK CONTENTS IFA-1 IS MARKED,COMPLETE ITEM C. 1a REGULAR 3 DIESEL. ❑ 6 AVIATION GAS A 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C ❑ UNLEADED ��-Jj 4 GASAHOL ❑ 7 METHANOL ❑ 2 PETROLEUM ❑ 80 EMPTY PRODUCT ❑ 1bUNLEAIDED ❑ 5 .LET FUEL ❑ 3 CHEMICAL PROOUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED ❑ 99 OTHER (DESCRIBE IN ITEM O. BELOW) D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S.s: III. TANK CONSTRU TION MARK ONE ITEM ONLY IN BOXES A,B.AND C,AND ALL THAT APPLIES IN SOX D AND E 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN A. TYPE OF SYSTEM ❑ 2 SINGLE WALL 4 SECONDARY CONTAINMENT (VAULTED TANK) 99 0 =113ARE EEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS 4 STEELCLADWIFIBERGLASSREINFORCEDPLASTICB. TANKTE6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM8 1005: METHANOL COMPATIBLE WIFRP MATERIAL(Primary Tank) ❑ 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 ❑ 95 UNKNOWN ❑ 99 OTHER LINING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO_ ❑ 1 POLYETHYLENE WRAP 2 COATING ❑ 3 VINYL WRAP 4 F RGLASS REINFORCED PLASTIC D.CORROSION95 UNKNOWN ❑ 99 OTHER g1 NONE PROTECTION ❑ 5 CATHODIC PROTECTION ❑ ❑ 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 U'lI 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 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 STEEL Wl COATING A U 8 100% METHANOL COMPATIBLE WIFRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION ❑ 1 AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING ❑ 3 MONRORCNG ❑99 OTHER V.TANK LEAK DETECTION E7-1 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VADOZE MONITOfl1NG 4 AUTOMATIC TANK GAUGING ❑ 5 GROUNDWATER MONYTORING 6 TANK TESTING ❑ 7 INTERSTITIAL MONITORING ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES ❑ NO ❑ 1.ESTIMATED DATE LAST USED(MO/DAYIYR) SUBSTANCE REMAINING GALLONS INERT MATERIAL? THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO TNF BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT DATE APPLICANT'S NAME (PRINT15D&SIGNATURE) LOCAL AGENCY USE ONLY THE STATE I.Q.NUMBER Is COMPOSED OFTHE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY# TANK# c L us 11 STATE I.D.# F- 5, ❑� I a �' 3 PERMIT NUMBER co APPROVED BYlOATE PERMIT EXPIRATION DATE // l l/,:AsL 2 FORMS (7-91) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. ✓�� FaRa