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s � ,eso�.�es STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD 3��. a _ UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B =�:"�� u' .o T �s.s .n1 oa. rCOMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE 8 TANK REMOVED {. DBA OR FACILITY NAME WHERE TANK IS INSTALLED: .:vfe-,3� V I. TANK DESCRIPTION COMPLETE ALL ITEMS-- SPECIFY IF UNKNOWN A. OWNER'S TANK I.D.a / B. MANUFACTURED BY: C. DATE INSTALLED(MO/DAY/4EAR) D. TANK CAPACITY IN GALLONS: / Q ILTANKCONTENTS IFA-11S MARKED,COMPLETE ITEM C. A �i MOTOR VEHICLE FUEL ❑ 4 OIL B. C 1a REGULAR ❑ 3 DIESEL ❑ UNLEADED 4 GASAHOL 6 AVIATION GAS �/--' ❑ ❑ 2 PETROLEUM ❑ 80 EMPTY 1PRODUCT 1DUNLEIUM ❑ 5 JET FUEL ❑ 7 METHANOL F—] 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN 777T""❑ 2 WASTE 2 LEADED ❑ 99 OTHER (DESCRIBE IN ITEM D. BELOW) D. IF(A.1)ISNOTMARKED, ENTER NAME OFSUBSTANCE STORED C.A.S.%: 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 F—] 2 STAINLESS STEEL 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE O 7 ALUMINUM ❑ 8 100'/6 METHANOL COMPATIBLE W/FRP (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL O 95 UNKNOWN ❑ 99 OTHER 1 RUBBER LINED 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING C.INTERIOR ❑ 5 GLASS LINING a UNLINED ❑ 95 UNKNOWN ❑ B9 OTHER LINING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES$ NO— D.CORROSION ❑ 1 POLYETHYLENE.WRAP X2 COATING ❑ 3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION = 91 NONE O95 UNKNOWN 89 OTHER E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) IV.PIPING INFORMATION CIRCLE A IFABOVEGROUNDOR U IF INDERGROUND.BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION U PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION U SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND A V BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A U 4 ERGLASS PIPE CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL W/COATING A U 8 100% METHANOL COMPATIBLE W/FRP 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 V2 LINE TIGHTNESS TESTING ❑ 3 MOE60BING ❑ 99 OTHER V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK 2INVENTORY RECONCILIATION ❑ 3 VADOZE MONITORING ❑ 4 AUTOMATIC TANK GAUGING❑ 5 GROUND WATER MONITORING TANK TESTING F-17 INTERSTITIAL MONITORING ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER 11 9N VI.TANK CLOSURE INFORMATION 1.ESTIMATED DATE LAST US D(MO/0 N 2.ESTIMATED OUANTITY OF 3.WAS TANK FILLED WITH YES N SUS STAN CE REMAWING1 46 GALLONS INERT MATERIAL? THIS ORM HAS B EN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANTS NAME DATE (PRINTED 8 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 I PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE FORM B (7.91) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. .Y,