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AP P��o8 .. STATE OF CALIFORNIA ..... p STATE WATER RESOURCES CONTROL BOARD a ° UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ONSITE ONE ITEM �� 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED 1 "'7 DBA OR FACILITY NAME WHERE TANK IS INSTALLED: Q�V '-1 `7 (%rii 64 L TANK DESCRIPTION COMPLETE ALL ITEMS -- SPECIFY IF UNKNOWN A. OWNER'S TANK I. D. # B. MANUFACTURED BY: C. 1a REGULAR ❑ 3 DIESEL ❑ 6 AVIATION GAS 4 GASAHOL C. DATE INSTALLED (MO/DAYNEAR) D. TANK CAPACITY IN GALLONS: ❑ 1bUNLEADED ❑ 5 JET FUEL PREMIUM 7 METHANOL 11 TANKr NTFNTq iFA-iIRMARKFlICnMPIFTFITFMC- A. 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C. 1a REGULAR ❑ 3 DIESEL ❑ 6 AVIATION GAS 4 GASAHOL _❑ 2 PETROLEUM ❑ 80 EMPTY 1 PRODUCT ❑ 1bUNLEADED ❑ 5 JET FUEL PREMIUM 7 METHANOL �❑ 3 CHEMICAL PRODUCT ❑ 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. # III TANK rONSTR[ICTION MARK ONE ITEM ONI- BOXES A. B. AND C. AND ALL THAT APPLIES IN BOX D A. TYPE OF ❑ 1 DOUBLE WALL 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM ❑ 2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER A U F—]1 BARE STEEL F72 STAINLESS STEEL F—]3 FIBERGLASS Ee4 STEEL CLAD W/ FIBERGLASS REINFORCED PLASTIC B. TANK MATERIAL 0 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 1009/ METHANOL COMPATIBLE W/FRP (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING❑ 3 EPDXY LINING F--]4 PHENOLIC LINING C. INTERIOR ❑ 5 GLASS LINING ❑ 6 UNLINED 95 UNKNOWN ❑ 99 OTHER LINING 6 CONCRETE A U 7 STEEL W/ COATING A U 8 100% METHANOL COMPATIBLE W/FRP PROTECTION A U Z: IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO 10 CATHODIC PROTECTION D. CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR 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 0 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER A U 1 BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE (PVC) A 0 4 FIBERGLASS PIPE C. MATERIAL AND CORROSION A U INUM A U 6 CONCRETE A U 7 STEEL W/ COATING A U 8 100% METHANOL COMPATIBLE W/FRP PROTECTION A U Z: 'A GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNO A U 99 OTHER D, LEAK DETECTION 1 AUTOMATIC LINE LEAK DETECTOR 0 2 LINE TIGHTNESS TESTING 3 INTERSTITIAL NTERS ITIA MONIT E::]99 OTHER J. TANK LEAK DETECTION 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VAPOR MONITORING J� 4 AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING �❑ 6 TANK TESTING V7 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 SUBSTANCE REMAINING GALLONS INERT MATERIAL? YES [:] NO ❑ THIS 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 # STATE I. D.# I TOM 1?izl PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE FORM B (9-90) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION - FORM A, UNLESS A CURRENT FORM A HAS BEEN FILED. • / /� / / � /1_ /_ 6/f FOR0034B-R4