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V STATE OF CALIFORNIA *mIf tom STATE WATER RESOURCES CONTROL BOARD s�P. UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B �" e m yi . 1 't COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM"°°�1� MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT Lf�5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ON SITI ONE ITEM O 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED ' DBA OR FACILITY NAME WHERE TANK IS INSTALLED: . I ANTI Ut,I.MIY I IUN COMPLETE ALL ITEMS -- SPECIFY IF UNKNOWN A. OWNER'S TANK I. D. # C>5 B. MANUFACTURED BY:11-1 411,74./e C. DATE INSTALLED (MO/DAY/YEAR) V h kflow h D. TANK CAPACITY IN GALLONS: /Z 000 II. TANK CONTENTS IFA -1 IS MARKED. COMPLETE ITEM C. A ©'f MOTOR VEHICLE FUEL ❑ 4 OIL8. ❑ 3 SINGLE WALL WITH EXTERIOR LINER C. ❑ Ia REGUL R SYSTEM 3 DIESEL ❑ 6 AVIATIONGAS F-]2 PETROLEUM F--180 EMPTY �� I' PRODUCT ❑ 1EPREMIUM ❑ 3 FIBERGLASS d GASAHOLEl7 ElMETHANOL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM UNLEADED El O 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 3 CHEMICALPRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE E::]2 LEADED ❑ 2 ALKYD LINING OTHERL(DESCRIBE IN ITEM D. BELOW) D. IF (AA) IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED ❑ 5 GLASS LINING ❑ 6 UNLINED C. A. S. # ❑ 98 OTHER III. TANK CONSTRNCTION MARKnNFITFM0NIY IN AnYFS A R 4Nnr 4M1411 THAT GPGI IC IN GnYll sunt/ A. TYPE OF ❑ 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER Or95 UNKNOWN SYSTEM ❑ 2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTEDTANK) ❑ 99 OTHER B. TANK ❑ i BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS O 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP (PNmaryTank) O 9 BRONZE ❑ 10 GALVANIZED STEEL E;�9S UNKNOWN ❑ 99 OTHER LEAK DETECTION ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING O 3 EPDXY LINING ❑ 4 PHENOLIC LINING C. INTERIOR ❑ 5 GLASS LINING ❑ 6 UNLINED E71-95 UNKNOWN ❑ 98 OTHER LINING IS LINING MATERIAL COMPATIBLE WITH 10D% METHANOL? YES_ NO— D. CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE Z95 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 IFAPPLICARLE A. SYSTEM TYPE A U 1 SUCTION p &h PRESSURE A U 3 GRAVITY A U 99 OTHER S. CONSTRUCTION A U 1 SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH p eA5 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�5 UNKNOWN A U 4 FIBERGLASS PIPE 8 100% METHANOL COMPATIBLE W/FRP 99 OTHER D. LEAK DETECTION 1 AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING ❑ IAON "11G ❑ 99 OTHER V. TANK LEAK DETECTION ❑ / VISUAL CHECK u L 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 =ATE NCE REMAINING GALLONS INERT MATERIAL? YES ❑ NOO 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 COUNTY # JURISDICTION # FACILITY # TANK # STATE I.D.# FK7� F -T7-1 I olol llJ 8 b S PERMIT NUMBER PERMITAPPROVED BY/DATE PERMIT EXPIRATION DATE 1-9-i2 FORM B (7-91) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION - FORM AYBNLESS A CURRENT FORM A HAS BEEN FILED ,y FOROMB.RS