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'' `� eR e STATE OF CALIFORNIA � i STATE WATER RESOURCES CONTROL BOARD s4 r. UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B �"� `° p 'YID n. �d COMPLETE 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 ❑ 8 TANK REMOVED / r J DBA OR FACILITY NAME WHERE TANK IS INSTALLED: GASAHOL ❑ 7 METHANOL L a f'Ai%p /� CHEMICAL PRODUCT L -, AA aP I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A. OWNER'S TANK I.D.40'7 MOTOR VEHICLE FUEL �4 OIL B. MANUFACTURED BY: C. DATE INSTALLED (MOIDAV/YEAR) ❑ 3 DIESEL Ej 6 AVIATIONGAS 6 D. TANK CAPACITY IN GALLONS: I (co I ILTANKCONTENTS IFA -11S MARKED -COMPLETE ITEM C. A ❑ 1 MOTOR VEHICLE FUEL �4 OIL B. LAR C. ❑ 1aUN ❑ 3 DIESEL Ej 6 AVIATIONGAS O 2 PETROLEUM O 80 EMPTY ❑ 1 PRODUCT❑ FADED lbUN GASAHOL ❑ 7 METHANOL O 3 CHEMICAL PRODUCT O 95 UNKNOWN WASTE EAIDUM D ❑ 2 LEADED ❑ 5 JETFUEL (Primary Tank) ❑ 9 BRONZE O 10 GALVANIZED STEEL �5 UNKNOWN F --j 99 OTHER �-99 OTHER (DESCRIBE IN ITEM D. BELOW) D. IF (A.1) IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED 0. 1 C. INTERIOR C. A. S. #: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.B.AND C. AND ALL THAT APPLIES IN BOX 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. TANK ❑ 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/ FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP (Primary Tank) ❑ 9 BRONZE O 10 GALVANIZED STEEL �5 UNKNOWN F --j 99 OTHER D. O 1 RUBBER LINED O 2 ALKYD LWING a 3 EPDXY LINING O 4 PHENOLIC LINING C. INTERIOR O 5 GLASS LINING O 6 UNLINED [?1'95 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 95 UNKNOWN ❑ B9 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. I. SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE p GRAVITY A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A(( ;M 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 4 FIBERGLASS PIPE 7 STEEL W/ COATING A U B 100% METHANOL COMPATIBLE W/FRP A )aS UNKNOWN A U 99 OTHER D. LEAK DETECTION ❑ 1 AUTOMATIC LINE LEAK DETECTOR E2"2 LINE TIGHTNESS TESTING ❑ MONITORING ❑ 99 OTHER I. TANK LEAK DETECTION 121�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 1. ESTIMATED DATE LAST USED(MO/DAY/YR) 2. ESTIMATED QUANTITY OF 3. WAS TANK FILLED WITH YES ❑ NO❑ SUBSTANCE REMAINING GALLONS INERT MATERIAL? TMS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANTS NAME DATE (PRINTED 8 SIGNATURE) LOCAL AGENCY USE ONLY THE STATE I.D. NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY # JURISDICTION # FACILITY # TANK # Or -SAL I y STATE LD.# �1 1J1 01 Oil 16 3181 dL6 3 >f d 7 PERMIT NUMBER PERMIT APPROVED BV/DATE PERMIT EXPIRATION DATE -9 /Z -T FORM B (7-91) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION • FORM A, UNLESS A C RENT FORM A HAS BEEN FILED. F/OR0031BR5 �/ � � Ill