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STATE OF CALIFORNIA "`b ." `o ' V i STATE WATER RESOURCES CONTROL BOARD ; g 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 ON SITI ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: Lawrence Livermore National Laboratory Site 300 1. TANK DESCRIPTION COMPLETE ALL ITEMS - SPECIFY iF UNKNOWN A OWNER'S TANK 1. D. M $75-D1U2 B. MANUFACTURED BY: Modern Welding Co., Inc. C. DATE INSTALLED(MO/DAY/YEAR) 7/20/92 D. TANK CAPACITY IN GALLONS: 3000 11. TANK CONTENTS IF A-1 IS MARKED. COMPLETE TEM C. A. a 1 MOTOR VEHICLE FUEL ❑ 4 OIL & C. to REGULAR UNLEADED lb PREMIUM SYSTEM 3 DIESEL ❑ 6 AVIATION GAS n ® 2 PETROLEUM a 80 EMPTY ® 1 PRODUCT UNLEADED 1c MMGRADE UNLEADED ❑ 3 FIBERGLASS 4 GASAHOL 7 METHANOL M85 ❑ 3 CHEMICAL PRODUCT ® 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED fp6M TYT"4) 5 JET FUEL II�J-1 8 99 OTHER (DESCRIBE IN ITEM D. BELOW) D. IF (A.i) IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED Diesel ❑ 99 OTHER c.A. S. #: N/A ® i RUBBER LINED 111. TANK CONSTRUCTION MARK ONE TEM 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 ® i 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 fp6M TYT"4) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER C. INTERIOR ® i RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING LINING OR ® 5 GLASS LINING ® 6 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES _ NO— N/A D. EXTERIOR ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC CORROSION PROTECTION ® 5 CATHODIC PROTECTION ❑ 91 NONE ❑ 95 UNKNOWN ® 99 OTHER �St P 1 clad with ME E SPILL AND OVERFILL, etc SPILL CONTAINMENT INSTALLED (YEAR) 1 993 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 * 90% Audible/Visual Alarm A. SYSTEM TYPE GO i SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND CORROSION PROTECTION A U A U A U i BARE STEEL 5 ALUMINUM 9 GALVANIZED STEEL A U 2 STAINLESS STEEL A U A U 6 CONCRETE A U A U 10 CATHODIC PROTECTION 3 POLYVINYL CHLORIDE (PVC U 4 FIBERGLASS PIPE 7 STEEL W/COATING A U 8 100% METHANOL COMPATIBLE W/FRP A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION ❑ 1 11ECFIAlACAL LAKE LEAK Q DETECTOA 2 tAaE 7KiHTlIESS a 3 cnNRnaT= MTEMTRML .❑ 4 ELECTRONIC LAK: O 5 AUTOLAnc PUMP Q 99 OTHER TESTING MdATCRIKS LEAK DETECTOR SHUTDOWN V. TANK LEAK DETECTION ❑ t VISUAL CHECK ❑ 2 MANUAL ❑ 3 VADOZEMONITORING 0 4 AUTOMATIC TANK ®5 GROUND MONITORING ❑ 6 ANNUALTESTING ® 7 MONITORING CONTINUICIUSINTERSTITIAL ❑ 8 SIR❑ 9 WEEKLY M NUAL ❑ 10 MONTHLY TANK ❑ 95 UNKNOWN ❑ 99 OTHER TAN Vl. TANK CLOSURE INFORMATION (PERMANENT CLOSURE IN -mu L ESTIMATED DATE LAST USED (MO/DAYNR) 2. ESTIMATED OUANTITY OF 3. WAS TANK FILLED WITH YES E]NO ❑ SUBSTANCE REMAINING GALLONS IINERT MATERIAL 7 THI FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AN9 TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORN TANK OWNER'S NAME DATE (PRINTEDBSMNATURE) C. Susi JacksonLz—:� — t2_l21 t � LOCAL AGENCY USE ONLY THE STATE LD. NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY # JURISDICTION • FACILITY # TANK # STATE I.D.4 m FM I I I-= PERNT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE ECT 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 PLAN. FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS FORM 8 (6,95) FORD NBA7 /A