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wfE V STATE OF CALIFORNIA `mw foi STATE WATER RESOURCES CONTROL BOARD 3`P G' ' UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B .p Yf ,�� d+ COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM PERMIT ❑ 3 RENEWAL PERMIT CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ON SITZ MARK ONLY ❑ 1 NEW ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT S TEMPORARY TANK CLOSURE ❑ B TANK REMOVED / J DBA OR FACILITY NAME WHERE TANK IS INSTALLED: ❑ 90 EMPTY 4 v ��ro� h L c+'hfCID _ COCCIFV IF I INKNONM 1. INIYr�ucovni�riv�. ^--••--- - -- A. OWNER'S TANK I. D. # 0-7 B. MANUFACTURED BY: vh k C. DATE INSTALLED (MO/DAWYEAR) VA 6 L7 r 0. TANK CAPACITY IN GALLONS: > IJ MAtlNC V. �t.mr�u c n gni... II. I ANR I IJN I [IY 15 IF A-1REGULAR .___. _.__. ❑ 3 SINGLE WALL WITH EXTERIOR LINER 95 UNKNOWN A. TYPE OF SYSTEM A ❑ 1 MOTOR VEHICLE FUEL �4 OIL B. C. ❑ 1aUNLEADED 3 DIESEL O g AVIATIONGAS O 2 PETROLEUM ❑ 90 EMPTY ❑ 1 PRODUCT 1b PREMIUM O UNLEADED ❑6 GASAHOL ❑ 7 METHANOL 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 A ) j C. A. S. # : ... �.. u. w......�r•.InTlnAl ... _.. _..�._�..— v---. a .ant can nlI T.AT.00l 1CC I IJ.1I n..f C ni. innrw vv................. ......... _.._.. _...___. ❑ 1 DOUBLE WALL .___. _.__. ❑ 3 SINGLE WALL WITH EXTERIOR LINER 95 UNKNOWN A. TYPE OF SYSTEM ❑ 2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTEDTANK) ❑ 99 OTHER B. ❑ 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEELCLAD W/ FIBERGLASS REINFORCED PLASTIC S. TANK MATERIAL F--]5 CONCRETE E::]e POLYVINYL CHLORIDE F]7 ALUMINUM 719 100% METHANOL COMPATIBLE WIFRP (PrimaryTank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL �6 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING 4 PHENOLIC LINING C. INTERIOR 5 GLASS LINING ❑ S UNLINED 1?r95 UNKNOWN ❑ 99 OTHER LINING 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION AI>.5 UNKNOWN A U 99 OTHER IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES _ NO— ❑ 1 AUTOMATIC LINE LEAK DETECTOR E�2 LINE TIGHTNESS TESTING ❑ 3 ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC D. CORROSION PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE 95 UNKNOWN O 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 A U 2 PRESSURE AGRAVITY FACILITY # A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A(1>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 S 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 AI>.5 UNKNOWN A U 99 OTHER D. LEAK DETECTION ❑ 1 AUTOMATIC LINE LEAK DETECTOR E�2 LINE TIGHTNESS TESTING ❑ 3 MOLAR TITIA ❑ 99 OTHER V. TANK LEAK DETECTION i VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VADOZE MONITORING ❑ 4 AUTOMATIC TANK GAUGING ❑ 5 GROUNDWATERMONITORING ❑ e TANK TESTING ❑ 7 INTERSTITIALMONITORING ❑ 9/ NONE ❑ 95 UNKNOWN ❑ 99 OTHER 1. ESTIMATED DATE LAST USED(MO/DAY/YR) 2. ESTIMATED QUANTITY OF 3.WAS TANKFILLEDWITH YES L—] 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 (PRIKED A SIGNATURE) LOCAL AGENCY USE ONLY THE STATE I.D. NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY # JURISDICTION # FACILITY # TANK IV STATE I.D.# r3iFl p v I ` 5 8 (al -&l PERMITNUMBER PERMIT APPROVED BY)DATE PERMIT EXPIRATION DATE 5z - FORM B (7-91) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION - FORM A, UNLESS A C RENT FORM A HAS BEEN FILED.