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•- � � nCP STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD ;�: a• g UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM B - n yf,:a �p COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY gL 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION O 7 PERMANENTLY CLOSEQ ON SITE ONE ITEM TLJ� 2 INTERIM PERMIT O 4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE E] B TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: - ?SO L' ti /^J a<- 6Ns/! 7r o � Q I. TANK DESCRIPTION COMPLETE ALL ITEMS-- SPECIFY IF UNKNOWN �I A. OWNER'S TANK I.D.# V 7.2 K NO w A.� B. MANUFACTURED BY: C. DATE INSTALLED(MO/DAV/YEAR) V a r w D. TANK CAPACITY IN GALLONS: O 00 II.TANK CONTENTS IFA-1 IS MARKED,COMPLETE ITEM C. A. ® 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. < C. ❑ 18UN UNLEADEDREGULAR 3 DIESEL ❑ e AVIATION GAS F--] 2 PETROLEUM ❑ W EMPTY �1 PRODUCTO ib PREMIUM 4 GASAHOL 7 METHANOL UNLEADED ❑ 5 JET FUEL ❑ 3 CHEMICAL PRODUCT O 95 UNKNOWN O 2 WASTE - O 2 LEADED ❑ 99 OTHER (DESCRIBE IN ITEM D. BELOW) D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S.#: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.8,AND C.AND ALL THAT APPLIES IN BOX D AND A. TYPE OF 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER O 95 UNKNOWN SYSTEM Q 2 SINGLE WALL 4 SECONDARY CONTAINMENT (VAULTED TANK) O 99 OTHER B. TANK ❑ 1 HARE STEEL O 2 STAINLESS STEEL 3 FIBERGLASS ® 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE O 6 POLYVINYL CHLORIDE 7 ALUMINUM O 9 100% METHANOL COMPATIBLE W/FRP (Primary Tank) ❑ 9 BRONZE ❑ 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 UNLINED95 UNKNOWN 99 OTHER N LINING ❑ ❑ o N C IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO_ D.CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC PROTECTION 5 CATHODIC PROTECTION ❑ 91 NONE O95 UNKNOWN ❑ 99 OTHER E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR) /9 AA: OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR)—Llv� IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION A© 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL AQl72 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(9 4 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL W/COATING A U B 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 O 1 AUTOMATIC LINE LEAK DETECTOR [0,2 LINE TIGHTNESS TESTING ❑ 3 MONITORING 99 OTHER filto V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VADOZE MONITORING [A4 AUTOMATIC TANK GAUGING ❑ 5 GROUNDWATER MONITORING ❑ 6 TANK TESTING 7 INTERSTITIAL MONITORING 91 NONE O 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION 1.ESTIM TED A LAST USED(MO/DAY/YR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH SUBSTANCE REMAINING GALLONS INERT MATERIAL 7 YES F] NO THIS F RM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF KNOWLEDGE, IS TRUE AND CORRECT APPLICANTS NAME �-44 .` i� DATE (PMNTEOaGIGNATUREI —� I - Akc.a4n LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE iOUR NUMBERS BELOW COUNTY# STATE LD.# JURISDICTION# AGILITY# TANK# FF Fl-f-1 O z PERMIT NUMBER PERMIT APPROVED BVIDATE PER EXPIRATION DATE FORM B (7-91) THIS FOR/HNNI BE OMPANIED BY A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. (7�� Naw -rhNl<- I v � qn� `' I4i�V FOl a¢M4R5