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zw^ce STATE OF CALIFORNIA \� �' _$ �`; STATE WATER RESOURCES CONTROL BOARD w,,,��- UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B , y,, �� COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ZT1 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ONSITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED-;/ DBA OR FACILITY NAME WHERE TANK IS INSTALLED: 1 yL/ y a 4-Ae O e 'C4. >Lk/ele LTIPAI n,cv ,e i iavununi n TAAIV PAKff CARO nuoi cTnTcurt F�l MOTOR VEHICLE FUEL A. OWNER'S TANK 1. D. D S. MANUFACTURED BY: vn Ado A14 rC. DATE INSTALLED(MO'DAWYEAR) Vn ��^ D. TANK CAPACITY IN GALLONS: �'�/ 000 n TAAIV PAKff CARO nuoi cTnTcurt F�l MOTOR VEHICLE FUEL ❑ 4 OIL B. C. ❑ taUNLEADE REGULAR 3 DIESEL ❑ 6 AVIATION GAS A ❑ 2 PETROLEUM ❑ SO EMPTY 1077-1 PRODUCT ❑ 10PREMIUM UNLEADED 4 GASAHOL ❑ 5 JETFUEL ❑ 7 METHANOL ❑ 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 4 FIBERGLASS PIPE C. A. S. x ❑ 2 ALKYD LINING 111 TAAIV PYIAICTGIICTIflN LAADV nuc IT[u nNl v IN 9nYP9 A P AND P. AND All THAT APPI IFR IN PDX D AND A. TYPE OF ❑ 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER 95 UNKNOWN SYSTEM ❑ 2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTEDTANK) ❑ 99 OTHER B. ❑ 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/ FIBERGLASS REINFORCED PLASTIC B. TANK MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP (PrimaryTank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL �5 UNKNOWN ❑ 99 OTHER 4 FIBERGLASS PIPE ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING C. INTERIOR ❑ 5 GLASS LINING ❑ 6 UNLINED O 95 UNKNOWN ❑ 99 OTHER LINING PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODICPROTECTION IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES— NO— 99 OTHER D. CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 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 IFABOVEGROUNDOR 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 p 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 STEE'L W-/ COATING A U 8 100% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODICPROTECTION An�5 UNKNOWN A U 99 OTHER D. LEAK DETECTION Q 1 AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING ❑ 3 ❑ 99 OTHER MONITORINGINTERSTITIAL V. TANK LEAK DETECTION ❑ 1 VISUAL CHECK Lff-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 1. ESTIMATED DATE LAST USED(MO/DAY/YR) 2. ESTIMATED QUANTITY OF 3. WAS TANK FILLED WITH YES E]NO❑ SUBSTANCE REMAINING GALLONS I INERTMATERIAL? THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANT'S NAME DATE IPRIHTED a SIGNATURE) LOCAL AGENCY USE ONLY THE STATE I.D. NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY # JURISDICTION # FACILITY # TANK # STATE LD.#FSci FT -T-1 I ol U I i I b I3 is ► b 3 5r v PERMITNUMBER PERMIT APPROVED BV/DATE PERMIT EXPIRATION GATE 9z FORM B (7-91) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION - FORM A, UNLES A CURRENT FORM A HAS BEEN FILED. wgo¢HaRs