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STATE OF CALIFORNIA = o STATE WATER RESOURCES CONTROL BOARD ' UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B r+t rwowµYS COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. ❑ 7 PERMANENTLY CLOSED ONSITE [DBA K O;FACILrrY ❑ 1 NEW PERMIT 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION E ITE ❑ 2 INTERIM PERMIT 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE 8 TANK REMOVED OR NAME WHERE TANK IS INSTALLED:I < I. TANK DESCRIPTION COMPLETE ALL ITEMS-- SPECIFY IF UNKNOWN 2 B. MANUFACTURED BY: f /I A. OWNER'S TANK I.D.#� V/V C. DATE INSTALLED(MOIOAYNEAR} U 0� D. TANK CAPACITY IN GALLONS: ILTANKCONTENTS IFR-1 IS MARKED.COMPLETE ITEM C. 1a REGULAR 3 DIESEL 6 AVIATIONGAS A 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C• ❑ UNLEADED ❑ 4 GASAHOL ❑ 7 METHANOL ❑ 2 PETROLEUM ❑ 80 EMPTY 1 PRODUCT ❑ 1bUNRLEMAIDDEMD ❑ 5 JET FUEL ❑ 3 CHEMICAL PRODUCT 95 UNKNOWN '❑ 2 WASTE ❑ 2 LEADED [_N4 99 OTHER (DESCRIBE IN ITEM D. BELOW} D. IF(A.I)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED Li } C.A.S.#: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A,B,AND C.AND ALL THAT APPLES IN BOX D AND E rA1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER K95 UNKNOWN 99 OTHER ❑ 2 SINGLE WALL 4 SECONDARY CONTAINMENT (VAULTED TANK} ❑ L_7 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W1 FIBERGLASS REINFORCED PLASTIC B. ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ B 100% METHANOL COMPATIBLE W1FRP L ❑ 5 CONCRETEnk} ❑ 9 BRONZE10 GALVANIZED STEEL 95 UNKNOWN ❑ 99 OTHERa i RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING R ❑ 5 GLASS LINING6 UNLINED 95 UNKNOWN ❑ 99 OTHER IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? YES, NO_1 POLYETHYLENE WRAP 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTICD, ION 91 NONE 95 UNKNOWN ❑ 99 OTHER PROTECTION ❑ 5 CATHODIC PROTECTION ❑ E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR)u {L�^� IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND,BOTH IF APPLICABLE FSYSTEM TYPE �AU 1 SUCTION A 2 PRESSURE A U 3 GRAVITY A U 99 OTHER UCTION 1 SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A 95 UNKNOWN A UI AL AND A U 1 BARE STEEL A U 2 S PAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVCI A U 4 FIBERGLASS PIOSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL W1 COATING A U 8 100% METHANOIFRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A5 UNKNOWN A U OTHER D. LEAK DETECTION ❑ 1 AUTOMATIC LINE LEAK DETECTOR '❑ 2 LINE TIGHTNESS TESTING ❑ 3 MONITORING 99 OTHER V.TANK LEAK DETECTION ❑ ❑ MONITORING ❑ 4 AUTOMATIC TANK GAUGING ❑ 5 GROUNDWATER MONITORING 1 VISUAL CHECK 2 INVENTORY RECONCILIATION F-] 3 VADOZE ❑ 6 TANK TESTING ❑ 7 INTERSTITIAL MONITORING ❑ 91 NONE 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED W iTH YES NO❑ 1S IMATED DATE LA^'JED(MO/DAY/YRI SUBSTANCE REMAINING � GALLONS INERT MATERIAL? THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, !$-TRUE AND CORRECT DATE APPLICANTS NAME � f 7 (PR�4 S SIG 1=1 �- � � � �• "'� r 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 BYIDATE PERMIT EXPIRATION DATE LLLL THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS FOR00348-Rfi FORM B (12-91)