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0 9 <br />STATE OF CALIFORNIA <br />STATE WATER RESOURCES CONTROL BOARD <br />UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B <br />COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. <br />MARK'ONLY 1 NEW PERMIT F-] 3 RENEWAL PERMIT EZ' 5 CHANGE OF INFORMATION <br />ONE ITEM O 2 INTERIM PERMIT O 4 AMENDED PERMIT a 6 TEMPORARY TANK CLOSURE <br />DBA OR FACILITY NAME WHERE TANK IS INSTALLED: Ae4-0 F'A(_ 1.10. O SSI <br />I. TANK DESCRIPTION COMPLETE ALL ITEMS -- SPECIFY IF UNKNOWN <br />A. OWNER'S TANK I. D. # B. MANUFACTURED BY: V utti� 0 1 <br />C. DATE INSTALLED (MO/DAY/YEAR) �rJ �� D. TANK CAPACITY IN GALLONS: SSQ�t <br />II. TANK CONTENTS IFA -1 IS MARKED. COMPLETE ITEM C. <br />SOURCES <br />P C� <br />P l <br />k R <br />aso <br />Cil i•OR N' O <br />7 PERMANENTLY CLOSED ON <br />8 TANK REMOVED <br />A. F7] 1 MOTOR VEHICLE FUEL E?"4 OIL <br />B. <br />C 0 to REGULAR 3 DIESEL 6 AVIATION GAS <br />2 PETROLEUM 80 EMPTY <br />1 PRODUCT <br />UNLEADED 4 GASAHOL <br />1bI[:] 5 JET FUEL Eil 7 METHANOL <br />UNLEADED <br />F73 CHEMICAL PRODUCT 0 95 UNKNOWN <br />Lk -2 WASTE <br />2 LEADED [k'gg OTHER (DESCRIBE IN ITEM D. BELOW) <br />D. IF (A.1) IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED V SE O h'IOTOQ OIL- C. A. S. #: 8oO� I <br />III. TANK CONSTRUCTION MARK Mr ITEM nNI Y IN Rr1YF8 A R ANn n ANn Al I TWAT ADDI ICc IKI anY n Anin c <br />A. TYPE OF <br />F-] 1 DOUBLE WALL <br />F7 3 SINGLE WALL WITH EXTERIOR LINER <br />0 95 UNKNOWN <br />SYSTEM <br />©'2 SINGLE WALL <br />4 SECONDARY CONTAINMENT (VAULTED TANK) <br />F__] 99 OTHER <br />B. TANK <br />[k"l BARE STEEL <br />❑ 2 STAINLESS STEEL <br />F__]3 FIBERGLASS <br />4 STEEL CLAD W/ FIBERGLASS REINFORCED PLASTIC <br />MATERIAL <br />0 5 CONCRETE <br />7 6 POLYVINYL CHLORIDE <br />F-] 7 ALUMINUM <br />8 100% METHANOL COMPATIBLE W/FRP <br />(Primary Tank) <br />9 BRONZE <br />El 10 GALVANIZED STEEL <br />95 UNKNOWN <br />0 99 OTHER <br />1 RUBBER LINED <br />a 2 ALKYD LINING <br />3 EPDXY LINING <br />F-]4 PHENOLIC LINING <br />C. INTERIOR <br />LINING <br />a 5 GLASS LINING <br />E2e6 UNLINED <br />95 UNKNOWN <br />E] 99 OTHER <br />IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? <br />YES_ NO <br />D. CORROSION <br />D 1 POLYETHYLENE WRAP <br />0 2 COATING <br />0 3 VINYL WRAP <br />0 4 FIBERGLASS REINFORCED PLASTIC <br />PROTECTION <br />5 CATHODIC PROTECTION 0 91 NONE <br />li?15 UNKNOWN <br />a 99 OTHER <br />E. SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED (YEAR) <br />OVERFILL PREVENTION EQUIPMENT INSTALLED (YEAR) <br />IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IFIJNDFRGRniINn RnTNIFADDI ICARIF <br />A. SYSTEM TYPE <br />A U <br />1 SUCTION <br />A U <br />2 PRESSURE A U <br />3 GRAVITY Ao <br />99 OTHER <br />B. CONSTRUCTION <br />A U <br />1 SINGLE WALL <br />A U <br />2 DOUBLE WALL A U <br />3 LINED TRENCH A U <br />95 UNKNOWN AID 99 OTHER <br />C. MATERIAL AND <br />CORROSION <br />PROTECTION <br />A U <br />A U <br />A U <br />1 BARE STEEL <br />5 ALUMINUM <br />9 GALVANIZED STEEL <br />A U <br />A U <br />A U <br />2 STAINLESS STEEL A U <br />6 CONCRETE A U <br />10 CATHODIC PROTECTION <br />3 POLYVINYL CHLORIDE (PVC) A U 4 FIBERGLASS PIPE <br />7 STEEL W/COATING A U 8 100°/ METHANOL COMPATIBLE W/FRP <br />A U 95 UNKNOWN AO 99 OTHER IJP <br />99 ►,jam <br />D. LEAK DETECTION <br />❑ 1 <br />AUTOMATIC LINE LEAK DETECTOR [:]2 LINE TIGHTNESS TESTING 3 I 7ERSTITIAL �99 OTHER <br />MONITORING <br />V. TANK LEAK DETECTION <br />�l VISUAL CHECK F-1 2 INVENTORY RECONCILIATION F-1 3 VADOZE MONITORING a 4 AUTOMATIC TANK GAUGING 5 GROUND WATER MONITORING <br />L�ofI6 TANK TESTING F__j 7 INTERSTITIAL MONITORING [�j 91 NONE F_� 95 UNKNOWN 99 OTHER <br />VI. TANK CLOSURE INFORMATION <br />1. ESTIMATED DATE LAST USED (MO/DAY/YR) 2. ESTIMATED QUANTITY OF 3. WAS TANK FILLED WITH <br />SUBSTANCE REMAINING GALLONS INERT MATERIAL? YES NO <br />THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT <br />APPLICANTS NAME DATE <br />(PRINTED 8 SIGNATURE <br />Z•Zl •qL <br />LOCAL AGENCY USE ONLY THE STATE I.D. NUMBER IS COMPO D OF THE FOUR NUMBERS BELOW <br />FORM B (7.91) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION -FORMA, UNLESS A CURRENT FORMA HAS BEEN FILED. <br />0 041' <br />FOR00348-RS <br />COUNTY # JURISDICTION # <br />FACILITY # TANK # <br />STATE I.D.# <br />PERMIT NUMBER <br />PERMIT APPROVED BY/DATE <br />PERMIT EXPIRATION DATE <br />FORM B (7.91) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION -FORMA, UNLESS A CURRENT FORMA HAS BEEN FILED. <br />0 041' <br />FOR00348-RS <br />