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- ptSOUAC'g C STATE OF CALIFORNIA AQP . p r STATE WATER RESOURCES CONTROL BOARD s g UNDERGROUND STORAGE TANK PERMIT APPLICATION -FORM B o •Cll if pp H+� COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM, MARK ONLY ❑ i NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ON SITE ONE ITEM ❑ 2 INTERIM PERMIT 4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE 8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: CHE V99N `i-g840 I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A OWNER'S TANK I.0.# B. MANUFACTURED BY: C. DATE INSTALLED(MO/DAY/YEAR) D. TANK CAPACITY IN GALLONS: /'000 II.TANK CONTENTS IF A-1 IS MARKED,COMPLETE ITEM C. A. ❑ 1 MOTOR VEHICLE FUEL 4 OIL B. C ❑ to REGULAR UNLEADED ❑ 3 DIESEL ❑ 6 AVIATION GAS lb PREMIUM UNLEADED ❑ 4 GASAHOL 7 METHANOL ❑ 2 PETROLEUM ❑ 80 EMPTY ❑ 1 PRODUCT ❑ 1c MIDGRADE UNLEADED ❑ 5 JET FUEL ❑ 8 M85 ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN 2 WASTE ❑ 2 LEADED ❑ 99 OTHER(DESCRIBE IN ITEM D.BELONG D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED 4*0 lno-lth40/4. a�wgf.7 C.A.S.#: &007_-0$-j III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A,B,AND C,AND ALL THAT APPLIES IN BOX D AND E A. TYPE OF ❑ 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 5 INTERNAL BLADDER SYSTEM ❑ 95 UNKNOWN SYSTEM 2 SINGLE WALL ❑ 4 SINGLE WALL IN A VAULT ❑ 99 OTHER B. TANK ❑ 1 BARE STEEL ❑ 2 STAINLESS STEEL x- 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE F--] 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER LINING ALKYD 1 RUBBER LINED 2 LD L3 EPDXY LINING 4 PHENOLIC LINING C.INTERIOR ❑ ❑ ❑ ❑ LINING OR ❑ 5 GLASS LINING 6 UNLINED a 95 UNKNOWN ❑ 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO— D. O_D CORROSION ❑ 1 POLYETHYLENE WRAP E:] 2 COATING ❑ 3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE E:195 UNKNOWN ❑ 99 OTHER E.SPILL AND OVERFILL etc. SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) + DROP TUBE YES NO STRIKER PLATE YES NO DISPENSER CONTAINMENT YES NO IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE AG 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION A0 1 SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND A U 1 BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A U 4 FIBERGLASS PIPE j CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL W/COATING A U 8 100% METHANOL COMPATIBLE W/FRP d PROTECTION AS U, `9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION [:]' MECHANICAL LINE LEAK 2 U ❑3 CONTINUOUS INTERSTITIAL 4 ELECTRONIC UNE TIGHTNESS NE 5 AUTOMATIC PUMP DETECTOR [:] TESTING MONITORING ❑ LEAK DETECTOR ❑ SHUTDOWN ❑ 99 OTHER - V.TANK LEAK DETECTION ❑ NUAL 1 VISUAL CHECK ED2 MANUALINVENTRECONCILIATIONORY F–] 3 MONITORING VADOZE ❑ 4 GAUGING AUTOMATIC TANK ❑ 5 MON TORINGGROUND WATER ❑ 6 TESTINGTANK ❑ 7 MONITOR CONTINUOUS ❑ 8 SIR ❑ 9 WE K LY MANUAL El 10 MOGIG TINLY TANK ❑ 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) ASA CNo✓P.oW ZD05 Alor c4o%e Tm*5, IAI ft—I)e _. LESTIMATED DATE LAST USED(MO/DAY/YR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES [:] .NO❑ SUBSTANCE REMAINING GALLONS INERT MATERIAL? THIS FORM HAS BEEN COMPLETED UNDER[PENALL1TY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT tiLpAt s TANK PR NITEDD&S GNATURE)WS E ttPA"a/"'x i wi+ � DAT LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY# TANK# STATE I.D.4 m PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. FORM C MUST BE COMPLETED FOR INSTALLATIONS.THIS FORM SHOULD BE ACCOMPANIED BY A PLOT POILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE RGROUND STORAGE TANK REGULATIONS FORM B (6-95)