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'�soo ce N! N%i STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B a .o OnMPI FTE A SEPARATE FORM FOR EACH TANK SYSTEM MARK ONLY ❑ 1 NEW PERMIT ❑ ONE ITEM ❑ 2 INTERIM PERMIT ❑ 3 RENEWAL PERMIT 4 AMENDED PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ONSITE ❑ 6 TEMPORARY TANK CLOSURE ❑ a TANK REMOVED /` J DBAOR FACILITY NAME WHERE TANK IS INSTALLED: B. �1 PRODUCT EADED ❑ OL 7 METHANOL 1b PREMIUED ❑ 2 PETROLEUM ❑ 60 EMPTY I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNUWN A OWNER'S TANK 1 D # O �, B. MANUFACTURED BY: Vn DA/d C DATE INSTALLED (MO/DAYNEAR) Vn �-or7✓ �l D. TANK CAPACITY IN GALLONS. o' 000 II. T ANY, CONTENTS 14A-1 IS __..__... _.._.__... G AR 3 DIESEL ❑ 6 AVIATION GAS C. ❑ 1aUN A MOTOR VEHICLE FUEL ❑ 4 OIL B. �1 PRODUCT EADED ❑ OL 7 METHANOL 1b PREMIUED ❑ 2 PETROLEUM ❑ 60 EMPTY % UNKNOWN ❑ ❑ 5 EATFUEL UNLEAD❑ 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. # : unTnunTrn atAnln AI I TWAT AV PI IFS IN Pnr n ANn F M. imV� __..__... _.._.__... _ 1 SUCTION A ❑ 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER % UNKNOWN A. TYPE OF SYSTEM ❑ 2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTEDTANK) ❑ 99 OTHER A U ❑ 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEELCLAD W/ FIBERGLASS REINFORCED PLASTIC B. TANK MATERIAL ❑ 5 CONCRETE 6 POLYVINYL CHLORIDE E]M ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP (PrimaryTank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL �5 UNKNOWN ❑ 99 OTHER 5 ALUMINUM ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING C. INTERIOR ❑ 5 GLASS LINING ❑ 6 UNLINED [ 95 UNKNOWN ❑ 99 OTHER LINING 10 CATHODIC PROTECTION ADS UNKNOWN A U 99 OTHER D. IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO— DETECTOR ❑ 2 LINE TIGHTNESS TESTING ❑ 3 D. CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING F--] 3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE ❑-95 UNKNOWN ❑ 99 OTHER E. SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED (YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED (YEAR) 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 A U 2 DOUBLE WALL A U 3 LINED TRENCH A 5 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 U 4 FIBERGLASS 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 ADS UNKNOWN A U 99 OTHER D. LEAK DETECTION 1 AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING ❑ 3 ❑ 99 OTHER MONBORING V. TANK LEAK DETECTION ❑ 1 VISUAL CHECK L �2 INVENTORY RECONCILIATION D 3 VADOZE MONITORING ❑ 4 AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING ❑ 6 TANK TESTING ❑ 7 INTERSTITIAL MONITORING ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER VI. TANK CLOSURE INFORMATION 1. ESTIMATED DATE LAST USED (MO/DAYNR) 2. ESTIMATED QUANTITY OF 3. WAS TANK FILLED WITH SUBSTANCE REMAINING GALLONS INERTMATERIAL? YES ❑ NO 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 OF THE FOUR NUMBERS BELOW FORM B (7-91) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION • FORM A, UNLES A CURRENT FORM A HAS BEEN FILED. FINOWBAS COUNTY # JURISDICTION # FACILITY # TANK # 15,44 / y STATE I.D.# -3 9 O O 6 3q I ► 11, 3 Y c-7 PERMrr NUMBER PERMIT APPROVED BYIDATE PERMIT EXPIRATION DATE �_ 9-9�- FORM B (7-91) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION • FORM A, UNLES A CURRENT FORM A HAS BEEN FILED. FINOWBAS