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i �■ I11 II I�� �souRces STATE OF CALIFORNIA r^ •�••. co: STATE WATER RESOURCES CONTROL BOARD 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 CLOSU E ❑ 8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: AQC[ o F-q` OZO I. TANK DESCRIPTION COMPLETE ALL ITEMS-- SPECIFY IF UNKNOWN A. OWNER'S TANK I.D.x '-U�-lLr 9- B. MANUFACTURED BY: u►.!I�j►.!o li.l r-I C. DATE INSTALLED(MO/DAY/YEAR) IZ -183 D. TANK CAPACITY IN GALLONS: Z 000 II.TANK CONTENTS IFA-1 IS MARKED,COMPLETE ITEM C. A. Ej�t< MOTOR VEHICLE FUEL ❑ 4 OIL B. C. [�aUNLEADREGULAR 3 DIESEL ❑ 6 AVIATION GAS F72 PETROLEUM ❑ 80 EMPTY �1 PRODUCT ❑ 1b PREMIUM 4 GASAHOL UNLEADED 5 JET FUEL ❑ 7 METHANOL ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN a 2 WASTE ❑ 2 LEADED D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED 99 OTHER (DESCRIBE IN ITEM D. BELOW) C.A.S.#: PA. ANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A,B,AND C,AND ALL THAT APPLIES IN BOX D AND E YPE OFOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UN NOWN SYSTEM [;J"2 NGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OT ER B. TANK 1 BARE STEEL ❑ 2 STAINLESS STEEL ©FIBERGLASS ❑ 4 STE L CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP (Primary Tank) ❑ g BRONZE ❑ 10 GALVANIZED STEEL 95 UNKNOWN ❑ 99 OTH R ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHEN LIC LINING C.INTERIOR LINING ❑ 5 GLASS LINING 0�6 UNLINED ❑ 95 UNKNOWN ❑ gg OTH R IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO— D.CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP 4 FIBER LASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE ❑95 UNKNOWN ❑ 99 OTH R I E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPME T INSTALLED(YEAR) IV,PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION A(�U:> PRESSURE A U 3 GRAVITY A U 99 THER B. CONSTRUCTION A U 1 SINGLE WALL U 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 NKNOWN A U 99 OTHER C. MATERIAL AND A U 1 BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) 4 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL W/COATINGA 8 100'/, METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A 99 OTHER D. LEAK DETECTION Ejer AUTOMATIC LINE LEAK DETECTOR ©2 LINE TIGHTNESS TESTING 031 1 I MONRORING ❑99 OTHER V.TANK LEAK DETECTION I;?', VISUAL CHECK 2 INVENTORY RECONCILIATION ❑ 3 VADOZE MONITORING ❑ 4 AUTOMATIC TANK GAU ING ❑ 5 GROUND WATER MONITORING ER"6 TANK TESTING ❑ 7 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 TAN FILLED WITH SUBSTANCE REMAINING GALLONS INERT ATERIAL? YES ❑ NO❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNO LEDGE, IS TRUE AND CORRECT APPLICANTS NAME DATE (PRINTED B SIGNATURE) p'j "ee-' 'Z-7A RZ- LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE F R NUMBERS BELOW COUNTY# JURISDICTION# FACILITY# TANK# f�2COS 17 STATE I.D.# � 5 5& v PERMITNUMBER PERMIT APP ROVED BY/DATE PERMITEXPIRATI NDATE q 5►2,-& FORM B (7.91) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. I_ FOR0034B-