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ia�<S STATE OF CALIFORNIA r per« "s STATE WATER RESOURCES CONTROL BOARD i UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B f��y`` COMPLETE A SEPARATE FORM FOR E2 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 CLOSURE ❑ 8 TANK REMOVED --I DBA OR FACILITY NAME WHERE TANK IS INSTALLED: ,aQL a �{aL tJ�. S L4S l� r P -X7 I. TANK DESCRIPTION COMPLETE ALL ITEMS -- SPECIFY IF UNKNOWN A. OWNER'S TANK I. D. Ir I _ lJ Ka L-_ TZ B. MANUFACTURED BY: CQ C. DATE INSTALLED (MO/DAY/YEAR) `O L / 5 D. TANK CAPACITY IN GALLONS: OOd ILTANKCONTENTS IFA -1 IS MARKED. COM PLETE ITEM C. A ❑MOTOR VEHICLE FUEL ❑ 4 OIL 8. C.1 'J _UNLEADED REGULAR ❑ 3 DIESEL ❑ 6 AVIATION GAS I� 2 PETROLEUM ❑ 80 EMPTY D?1-1- PRODUCT ❑ 1yUNLEAPREMIUM [:]4 GASAHOL El7 METHANOL 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE DED ❑ 5 JET FUEL ❑ 2 LEADED ❑ 99 OTHER (DESCRIBE IN ITEM D. BELOW) D. IF (A.1) IS NOT MARKED. ENTER NAME OF SUBSTANCE STORED C. A. S. III: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN ROXFS A R ANO( ANO Al I TWAT APPI IFC IN Dny n akin c A. TYPE OF E ' DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER =❑ 95 UNKNOWN SYSTEM ❑ 2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTEDTANK) ❑ 99 OTHER B. TANK F-]1 BARE STEEL F--]2 STAINLESS STEEL 3 FIBERGLASS ❑ 4 STEEL CLAD W/ FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM l❑ 8 100% METHANOL COMPATIBLE W/FRP (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING C. INTERIOR F7I►I 5 GLASS LINING 6 UNLINED El95 UNKNOWN ❑ 99 OTHER LINING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO_ D. CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER E. SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED (YEAR) 191B-7 OVERFILL PREVENTION EQUIPMENT INSTALLED (YEAR) IV. PIPING INFORMATION CIRCIF A IF ARnVF C;RC1l1Nr)(1R Ll IF I INnFRARnI INn Pr1TW IC ADDI If A0I A. SYSTEM TYPE A U 1 SUCTION A (D2 PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL A U 2 DOUBLE WALL AID3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND CORROSION PROTECTION A U A U A U 1 BARE STEEL 5 ALUMINUM 9 GALVANIZED STEEL A U A U A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE (PVC) A U 6 CONCRETE A U 7 STEEL W/ COATING A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 4 FIBERGLASS PIPE 8 100% METHANOL COMPATIBLE W/FRP 99 OTHER D. LEAK DETECTION ❑ 1 AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESSTESTING IN I A MONITORING ❑ gg OTHER V. TANK LEAK DETECTION 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VADOZE MONITORING ❑ 4 AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING ❑ 6 TANK TESTING ❑� ' 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 TANK FILLED WITH YES ❑ NO ❑ SUBSTANCE REMAINING GALLONS INERT MATERIAL? THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT LOCA 4PPLICANT'S NAME DATE PRINTED 8 SIGNATURE) q►_l. �1G11�.lEem&Z Z•Zt .QL AGENCY USE ONLY THE STATE I.D. NUMBER IS COMPOSED OF THE FOUR N MBERS BELOW `7 COUNTY # JURISDICTION # FACILITY # TANK # STATE I. D.# ��, l 1 [m] Z PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE FORM B (7-91) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION - FORM A, UNLESS A CURRENT FORM A HA E �iZ 4;:�47 141-