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n FS C ^ 'ti JJ �t STATE OF CALIFORNIA � STATE WATER RESOURCES CONTROL BOARD w� ��' „� UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B `.a��,� ,.' rnMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 'CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ONSITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ B TANK REMOVED a7 - DBA OR FACILITY NAME WHERE TANK IS INSTALLED: A/y �/ � 5'f ^ )-A �'-v I. TANK DE5GHII'IWIN COMPLETE ALL IIEMS"srcur111-1......i. A OWNER'S TANK I D # Q / B. MANUFACTURED BY: vh �, /�pA/q C DATE INSTALLED(MO/DAY/YEAR) "ni'dOv✓1 D. TANK CAPACITY IN GALLONS: II. TANK GUNILIN Ia IFA-115MAHKEU.cVMrLeIc Ic-- I _...___._-.-_.-.. SINGLE WALL WITH EXTERIOR LINER 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. 3 DIESEL ❑ g AVIATION GAS C. ❑ 1eREGULARUN UNLEADED A O 2 PETROLEUM ❑ Fal EMPTY 1 PRODUCT 1D PREMIUM 4 GASANOL ❑ 7 METHANOL ❑ UNLEADED ❑ 5 JETFUEL ❑ 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.#: 111. IMPIIY oi..n,....- . I _...___._-.-_.-.. SINGLE WALL WITH EXTERIOR LINER — 95 UNKNOWN PRESSURE A U ❑ i DOUBLE WALL ❑ 3 A U u A. TYPE OF SYSTEM ❑ 2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTEDTANK) ❑ 99 OTHER A U A U A U ❑ 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/ FIBERGLASS REINFORCED PLASTIC B. TANK MATERIAL ❑ s CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP (Pflmuy Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL95 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED ❑ 2 ALKYO LINING ❑ 3 EPDXY LINING 4 PHENOLIC LINING C. INTERIOR O 5 GLASS LINING ❑ 6 UNLINED �95 UNKNOWN ❑ 99 OTHER LINING 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 Q'66 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 1 SUCTION A 02 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 p e.15 UNKNOWN A U 99 OTHER C. MATERIAL AND CORROSION PROTECTION A U A U A U 1 BARE STEEL 5 ALUMINUM 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 7 STEEL W/COATING A U A©95 UNKNOWN A U 4 FIBERGLASS PIPE 8 100% METHANOL COMPATIBLE W/FRP 99 OTHER D. LEAK DETECTION1 AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING ❑ 3MONRORING ❑ 99 OTHER V. TANK LEAK DETECTION ❑ 1 VISUAL CHECK 2 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 VI. TANK CLOSURE INFORMATION 1. ESTIMATED DATE LAST USED (MO/DAY/YR) 2. ESTIMATED QUANTITY OF 3. WAS TANK FILLED WITH YES E::] 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 ppTE (PRINTED 8 SIGNATURE) LOCAL AGENCY USE ONLY THE STATE I.D. NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW FORM B (741) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION - FORM A, UNLESS A CURRENT FORM A HAS BEEN FILED. FOR0WBR5 COUNTY# JURISDICTION# FACILITY# TANK# O(SAL /y STATE LD.# ® = IcLp j Ellt3 8 n PERMRNUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE If4 FORM B (741) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION - FORM A, UNLESS A CURRENT FORM A HAS BEEN FILED. FOR0WBR5