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I. TANK DESCRIPTION COMPLETE ALL ITEMS— SPECIFY IF UNKNOWN <br />A. OWNERS TANK I.D.# S. MANUFACTURED BY: jrp <br />C. DATE INSTALLED (MO/DAY/YEAR) / D. TANK CAPACITY IN GALLONS: <br />II.TANKCONTENTS IFA -1 IS MARKED. COMPLETE ITEM C. / <br />A. 1 MOTOR VEHICLE FUEL❑ 4 OIL <br />B. <br />C. is REGUL R ❑ 3 DIESEL ❑ 6 AVIATION GAS <br />❑ 2 PETROLEUM ❑ 60 EMPTY <br />1 PRODUCT <br />❑ lb PRFMIDM F--15 ETFUEL ❑ 7 METHANOL <br />UNLEA❑ <br />3 CHEMICALPRODUCT ❑ 95 UNKNOWN <br />STATE OF CALIFORNIA <br />❑ 2 LEADED ❑ 99 OTHER (DESCRIBE IN ITEM D. BELOW) <br />D. IF (A.1) IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C. A. S. S : <br />❑ 2 STAINLESS STEEL <br />❑ 3 FIBERGLASS <br />4 STEEL CLAD W/ FIBERGLASS REINFORCED PLASTIC <br />B. TANK <br />C. <br />MATERIAL AND <br />A U <br />STATE WATER RESOURCES CONTROL BOARD <br />MATERIAL <br />s` <br />❑ 6 POLYVINYL CHLORIDE <br />❑ 7 ALUMINUM <br />UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B <br />(PrimaryTank) <br />❑ 9 BRONZE <br />❑ 10 GALVANIZED STEEL <br />❑ 95 UNKNOWN <br />❑ 99 OTHER <br />PROTECTION <br />❑ 1 RUBBER LINED <br />n I.KYD LINING <br />❑ 3 EPDXY LINING <br />❑ 4 PHENOLIC LINING <br />C. INTERIOR <br />❑ 5 GLASS LINING <br />6 UNLINED <br />COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. <br />❑ 99 OTHER <br />LINING <br />MARK ONLY <br />❑ <br />1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION <br />❑ 7 PERMANENTLY CLOSEDONSITE <br />ONE ITEM <br />❑ <br />2 INTERIM PERMIT ❑ 4 PERMIT ❑ 6 TEMPORARY TANK CLOSURE <br />❑ B TANK REMOVED <br />� <br />T-1 <br />1 <br />1 <br />JJ7AMENDED <br />DBA OR FACILITY NAME WHERE TANK IS INSTALLED: (� 2a F_ . ` uj-iJ _ , <br />t // <br />_ <br />I. TANK DESCRIPTION COMPLETE ALL ITEMS— SPECIFY IF UNKNOWN <br />A. OWNERS TANK I.D.# S. MANUFACTURED BY: jrp <br />C. DATE INSTALLED (MO/DAY/YEAR) / D. TANK CAPACITY IN GALLONS: <br />II.TANKCONTENTS IFA -1 IS MARKED. COMPLETE ITEM C. / <br />A. 1 MOTOR VEHICLE FUEL❑ 4 OIL <br />B. <br />C. is REGUL R ❑ 3 DIESEL ❑ 6 AVIATION GAS <br />❑ 2 PETROLEUM ❑ 60 EMPTY <br />1 PRODUCT <br />❑ lb PRFMIDM F--15 ETFUEL ❑ 7 METHANOL <br />UNLEA❑ <br />3 CHEMICALPRODUCT ❑ 95 UNKNOWN <br />❑ 2 WASTE <br />❑ 2 LEADED ❑ 99 OTHER (DESCRIBE IN ITEM D. BELOW) <br />D. IF (A.1) IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C. A. S. S : <br />III. TANK CONSTRUr-116N MARK ONF REM ONLY IN BOXES A.B.AND C. AND ALLTHAT APPLIES IN BOX D AND <br />A. TYPE OF <br />1 DOUBLE WALL <br />❑ 3 SINGLE WALL WITH EXTERIOR LINER <br />❑ 95 UNKNOWN <br />SYSTEM <br />2 SI LE WALL <br />❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) <br />❑ OTHER <br />CONSTRUCTION <br />BARE STEEL <br />❑ 2 STAINLESS STEEL <br />❑ 3 FIBERGLASS <br />4 STEEL CLAD W/ FIBERGLASS REINFORCED PLASTIC <br />B. TANK <br />C. <br />MATERIAL AND <br />A U <br />1 BARE STEEL <br />MATERIAL <br />5 CONCRETE <br />❑ 6 POLYVINYL CHLORIDE <br />❑ 7 ALUMINUM <br />❑ B 100% METHANOL COMPATIBLE W/FRP <br />(PrimaryTank) <br />❑ 9 BRONZE <br />❑ 10 GALVANIZED STEEL <br />❑ 95 UNKNOWN <br />❑ 99 OTHER <br />PROTECTION <br />❑ 1 RUBBER LINED <br />n I.KYD LINING <br />❑ 3 EPDXY LINING <br />❑ 4 PHENOLIC LINING <br />C. INTERIOR <br />❑ 5 GLASS LINING <br />6 UNLINED <br />❑ 95 KNOWN <br />❑ 99 OTHER <br />LINING <br />IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? <br />VES NO_ <br />D. CORROSION <br />❑ 1 POLYETHYLENE WRAP <br />❑ 2 COATING <br />❑ 3 VINYL WRAP <br />4 FIBERGLASS REINFORCED PLASTIC <br />PROTECTION <br />❑ 5 CATHODIC PROTECTION <br />❑ 91 NONE <br />❑95 UNKNOWN <br />❑ 99 OTHER <br />E. SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED (YEAR) <br />OVERFILL PREVENTION EQUIPMENT INSTALLED (YEAR) <br />IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND, BOTH IF APPLICABLE <br />A. <br />SYSTEM TYPE <br />AV <br />1 SUCTION <br />A U <br />2 PRESSURE A U 3 GRAVITY <br />A U 99 OTHER <br />B. <br />CONSTRUCTION <br />AMI <br />SINGLE WALL <br />A U <br />2 DOUBLE WALL A U 3 LINED TRENCH <br />A U 95 UNKNOWN A U 99 OTHER <br />C. <br />MATERIAL AND <br />A U <br />1 BARE STEEL <br />A U <br />2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE (PVC) A U 4 FIBERGLASS PIPE <br />CORROSION <br />A U <br />5 ALUMINUM <br />A U <br />8 CONCRETE U STEEL W/COATING <br />A U B 100% METHANOL COMPATIBLE W/FRP <br />PROTECTION <br />A U <br />9 GALVANIZED STEEL <br />A U <br />10 CATHODIC PROTECTI A U 95 UNKNOWN <br />A U 99 OTHER <br />D. <br />LEAK DETECTION <br />❑ 1 <br />AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING ❑MONBORING <br />99 OTHER <br />V. TANK LEAK DETECTION <br />❑ 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VADOZE MONITORING ❑ 4 AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING <br />❑ 6 TANK TESTING VI 7 INTERSTITIAL MONITORING ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER <br />VI. TANK CLOSURE INFORMATION <br />11. EATED TS LAST USED (MO/DAV/YR) 2. ESTIMATED OFTANK FILLED W <br />SUBSTANCE REMAII TY NG _ '&_GALLONS S WASINERTMATERIAL?H VES ❑ NO ❑ <br />1 <br />THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT <br />(PRINTED A SIGNATURE) <br />"a ENCY USE ONLY <br />THE STATE I.D. NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW I h r lee <br />STATE I.D.# <br />COUNTY III <br />r <br />JURISDICTION III FACILITY# TANK# <br />FORM B (7-91) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION - FORM A, UNLESS A CURRENT FORM A HAS BEEN FILED. <br />-�/_� 7 — 9a-'5 FDNO¢id9.95 <br />