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R PS t tv. Pct • STATE OF CALIFORNIA � STATE WATER RESOURCES CONTROL BOARD w�� B UNDERGROUND STORAGE TANK PERMIT APPLICATION • FORM B "oR y.i„1 Iys ue Y.. COMPLETE a RFPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT ❑ ONE ITEM ❑ 2 INTERIM PERMIT ❑ 3 RENEWAL PERMIT 4 AMENDED PERMIT u 5 CHANGE OF INFORMATION O 6 TEMPORARY TANK CLOSURE ❑ 7 PERMANENTLY CLOSED ONSITE B TANK REMOVED T7 �J DBAOR FACILITY NAME WHERE TANK IS INSTALLED: ALL, `,4 fJl 1' I< rr�• //❑ h � f1"�4P I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A. OWNERS TANK D # O/ B. MANUFACTURED 8V: C DATE INSTALLED(MO'DAY/YEAR) 1/#I /��t/•% D. TANK CAPACITY IN GALLONS. II. I AINK L.UIN I E:IN 10 IFA-( FUEL ED OIL B. REGULAR C. ❑ taUN DIESEL ❑ 6 AVIATION GAS A 1❑ MOTOR VEHICLE ❑ BO EMPTY Z�1 PRODUCT UNLEADED ❑ 1b PREMIIUM❑ OL ❑ 7 METHANOL GASAHJET 2 PETROLEUM ❑ 2 STAINLESS STEEL UNLEADED❑ 5 L 3 CHEMICALPRODUCT ❑ 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. # nnrinu i eool ¢R Iu Rnr n eun F ❑ 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER �5 UNKNOWN A. TYPE OF SYSTEM ❑ 2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER B. 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEELCLAD W/ FIBERGLASS REINFORCED PLASTIC B. TANK MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL 5 UNKNOWN ❑ 99 OTHER Q l AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING ❑ 3 ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING C. INTERIOR ❑ 5 GLASS LINING ❑ 6 UNLINED 95 UNKNOWN ❑ 99 OTHER LINING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? VES _ NO_ D.CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE UNKNOWN ❑ 99 OTHER E. SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED (YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED (YEAR) IV. PIPING INFORMATION CIRCLE A IFABOVEGROUNDOR U IF UNDERGROUND, BOTH IF APPLICABLE A. SYSTEM TYPE A U/ SUCTION p 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A ®95 UNKNOWN A U 99 OTHER C. MATERIAL AND CORROSION PROTECTION A U 1 BARE STEEL A U 5 ALUMINUM A U 9 GALVANIZED STEEL A U A U A U 2 STAINLESS STEEL A U 6 CONCRETE A U 10 CATHODIC PROTECTION 3 POLYVINYL CHLORIDE (PVC) A U 4 FIBERGLASS PIPE 7 STEEL W/ COATING A U B 100% METHANOL COMPATIBLE W/FRP A05 UNKNOWN A U 99 OTHER D. LEAK DETECTION Q l AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING ❑ 3 MONITORING[:] 99 OTHER V. TANK LEAK DETECTION ❑ i VISUAL CHECK I/I a INVENTORY RECONCILIATION ❑ 3 VADOZE MONITORING ❑ 4 AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING ❑ 6 TANK TESTING ❑ 7 INTERSTITIAL MONITORING ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER 1. ESTIMATED DATE LAST USED (MO/DAV/YR) 2. ESTIMATED QUANTITY OF I 3. WAS TANK FILLED WITH YES ❑ NO ❑ SUBSTANCE REMAINING GALLONS INERT MATERIAL? THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANTS NAME DATE (PRINTED A SIGNATURE) LOCAL AGENCY USE ONLY THE STATE I.D. NUMBER IS COMPOSED OFTHE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY# TANK# 0I-nr4l- Iy STATE I.D.# FlTq-1 = I I Ia -allciI PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT -EXPIRATION DATE PERMIT NUMBER --7� %- 9Z FORM B (7-91) 1 HIS I-UNM MUST lit AUCUMPANILU BY A PLHMli APPLICATION - FORM A, UNLESS A CURRENT FORM A HAS BEEN FILED. A40 FOBORfaBAS