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>T URC S .. STATE OF CALIFORNIA ? } Y•� P STATE WATER RESOURCES CONTROL BOARD a ' 61 ' UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B ' COMPLETE A,SEPARATE FORM FOR EACH TANK SYSTEM. k MARK ONLY ❑ EWAL 1 NEW PERMIT ❑ 3,RENPERMIT ❑ 5 CHANGE OF INFORMATION 7 PERMANENTLY'CLbSED ONSITE ONE ITEM ❑]..':2 INTERIM PERMIT ❑ 4 AMEN6&PERMIT. ❑ 6 TEMPORARY TANK CLOSURE 8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: _3 6 I. TANK DESCRIPTION COMPLETE ALL ITEMS-- SPECIFY IFUNKNOWN A. OWNER'S TANK I.D A ( y y } B. MANUFACTURED BY: 4� C. DATE INSTALLED(MO/DAY/YEAR) � D. TANK CAPACITY IN GALLONS: �i coo F ILTANKCONTENTS IF: IS MARKED,COM PLETEITEMC. �✓ REGULAR A w 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C. ❑ 1aUNLEADED 3 DIESEL ❑ 6 AVIATION GAS 2 PETROLEUM 0 80 EMPTY F�Z, 1 PRODUCT ❑ lb PREMIUM 4 GASAHOL ❑ 7 METHANOL UNLEADED ❑ 5 JET FUEL ,a<j 3 CHEMICAL PRODUCT 95 UNKNOWN rr 2 LEADED 2 WASTE ❑ ❑ 99 OTHER (DESCRIBE IN ITEM D. BELOW) "- D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S:#: �y (II. TANK CONSTRUCTION: MARK ONE ITEM ONLY IN BOXES A,B,AND C,AND ALL THAT APPLIES IN BOX D AND E A. TYPEOF ❑ 1 DOUBL_E;WALL ❑ 8 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM" , V� 2 SINGLE WALL ❑ 4 'SECONDARY CONTAINMENT (VAULTEDTANK) ❑ 99 OTHER B. TANK R! BARE STEEL ❑ 2 STAINLESS STEEL `;❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑` CONCRETE } ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ B 100% METHANOL COMPATIBLE W/FRP (PrimgyTank) ❑..g BRONZE ❑ '10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER 1 RUBBER LINED F7 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING' C.INTERIOR LINING 6 GLASS LINING 6 UNLINED 95 UNKNOWN 99.OTHER ❑ ❑ , PI$LINING MATERIAL COMPATIBLE WITH 100% METHANOL? L YES— NO— t. O_ �. ORROSION' i POLYETHYLENE WRAP ❑ 2" COATING ❑ 3 VINYL WRAP E:] 4 FIBERGLASS REINFORCED PLASTIC fPROTECTION ❑ 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 IF ABOVE GROUND OR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION A B. CONSTRUCTION 1 SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN p U 99 OTHER C. MATERIAL AND A U 1 BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLO IDE(PVC)A U 4 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL W/COATINGA`V 8 1WI METHANOL COMPATIBLE W/FRP z-PROTECTION A U 9 GA.I_VAN17ED STEEL ,A;U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 ,QTMER., D: LEAK DETECTION 1 AUTOMATIC LINE LEAK DETECTOR 2 LINE TIGHTNESS TESTING 3 IN I ERSII IAL MONITORING ❑ 99 OTHER v.TANK LEAK DETECTION }. 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VADOZE MONITORING ❑ 4 AUTOMATIC TANAUGING 0 5 GROUND WATER MONITORING ❑ 6 TANK TESTING ❑ 7 INTERSTITIAL MONITORING ❑❑ 91 NONE [;- 5 5 UNKNOWN ❑ 99 OTHER VIjgK CLMRE INFORMATION 1.EST], ID LAST US D MO DAY/YR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES ❑ NO ❑� G? ,� ]�+ "R,SUBSTANC REMAINING . GALLONS INERT MATERIAL? TH►sem f6RM HAS BEEN.GfQMPLETED UNCI P NALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT ' APPLICANT'S NAME r - 1 flpTE (PRINTED&SIGNATURE] '1 1 - �` LIt bCAL AG ENCY USE ONLY THE STATE I.D.NUMBER IS COMPQStD OF THE FOUR NU ERS BELOW COUNTY# JURISDICTION# FACILITY# TANK# r'vI `STATE I.D.# x PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE s FORIA B(7-91) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILE � - FOR0034B-RS E ,�,'