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• � � � X60 yRCe STATE OF CALIFORNIA r c° 9 STATE WATER RESOURCES CONTROL BOARD a ° UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM B 114 COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM- MARK ONLY 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ONSITE ONE ITEM 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 5 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED or DBA OR FACILITY NAME WHERE TANK IS INSTALLED: f 7 + 1. TANK DESCRIPTION COMPLETE ALL ITEMS-- SPECIFY IF UNKNOWN A, OWNERS TANK I,D.a B. MANUFACTURED BY: it, ,r �._ C. DATE INSTALLED(MOIDAYIYEAR) D. TANK CAPACITY IN GALLONS: t�©0 IL TANK CO ENTS IFA-1 IS MARKED,COMPLETE ITEM C. A C 1 MOTOR VEHICLE FUEL ❑� 4 OIL B. C. 1a REGULAR DED ❑ 3 DIESEL ❑ 6 AVIATION GAS [� 1 PRODUCT 1b 2 PETROLEUM �❑ 80 EMPTY ❑ PREMIUM ❑ 4 GASAHOL ❑ 7 METHANOL UNLEADED ❑ 5 JET FUEL 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.x: 111. TANK CONSTRUCTIpN MARK ONE ITEM ONLY IN BOXES A.S.AND C,AND RLL THAT APPLIES IN BOX D A. TYPE OF L 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM ❑ 2 SINGLE WAIL ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER ❑ B. TANK 1 BARE STEEL ❑ 2 STAINLESS STEEL F] 3 FIBERGLASSEjo-1114 STEEL CLAD WI FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE WIFRP (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED ❑ 2 LKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LIMING C.INTERIOR F75 GLASS LINING 6UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER LINING IS LINING MATERIAL COMPATIBLE WITH lDo% METHANOL? YE NO D.CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP 5Z 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE lw 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL U DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND A.0 1 BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYV6NYL CHLORIDE(PVC)A U[4 jIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL WICOATING A U B 500°! 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 L-11 AUTOMATIC LINE LEAK DETEC T�R ❑ 2 LINE TIGHTNESS TESTING ❑ 3 IMNOTERSTITIAL NITORING 99 OTHER-+ ' V.TANK LEAK DETECTION L-] 1 VISUAL CHECK 2 INVENTORY RECONCILIATION ❑ 3 VAPOR MON}TORING❑ 4 AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING 1-1 6 TANK TESTING 7 INTERSTITIAL MONITORING ❑ 91 NONE E❑ 95 UNKNOWN ❑ 99 OTHER VI,TANK CLOSURE INFORMATION 1.ESTI T' D TE LAST USED(MO/DAYNR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH SUBSTANCE REMAINING LONS INERT MATERIAL? YES ❑ NO GAL ❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANTS NAME DATE (PRINTED B SIGNATURE) LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY# TANK# STATE I.D.# PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE FORM B (9-90) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED.. a� 4V'% FOBOIX99B•R4 SJ V a— q "J i