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STATE OF CALIFORNIA <br />B. <br />u-fos <br />^•• °<, <br />r: <br />STATE WATER RESOURCES CONTROL BOARD <br />UNDERGROUND STORAGE <br />�� PRODUCT <br />W At <br />TANK PERMIT APPLICATION - FORM <br />B <br />UNLEADED a 5 JET FUEL L_ <br />2 LEADED <br />O 1 BARE STEEL <br />2 STAINLESS STEEL <br />r �•r <br />COMPLETE A SEPARATE FORM FORE TANK SYSTEM. <br />MATERIAL <br />5 CONCRETE <br />MARK ONLY 0 1 NEW PERMIT 3 RENEWAL PERMIT Wl'CHANGE OF INFORMATION <br />a 7 PERMANENTLY CLOSED ON SITE <br />ONE ITEM 71 2 INTERIM PERMIT 4 AMENDED PERMIT En 6 TEMPORARY TANK CLOSURE <br />8 TANK REMOVED <br />DBA OR FACILITY NAME WHERE TANK IS INSTALLED: ,per p �L N p �i ' / <br />C,,V /t <br />95 UNKNOWN <br />I. TANK DESCRIPTION COMPLETE ALL ITEMS -- SPECIFY IF UNKNOWN <br />a 1 RUBBER LINED <br />A. OWNER'S TANK I.D.# 2_ VNJL--R- B. MANUFACTURED BY: E �5 Lp21.LItiLC� <br />C. DATE INSTALLED (MO/DAYNEAR) 10 /-/87 D. TANK CAPACITY IN GALLONS: <br />II. TANK CONTENTS IFA-11.SMARKFnrnMPIFTFITFMr <br />A. 1 MOTOR VEHICLE FUEL 4 OIL <br />B. <br />REGULAR3 DIESEL 6 AVIATION GAS <br />C. �aUN Ej <br />a 2 PETROLEUM a 80 EMPTY <br />�� PRODUCT <br />G DED <br />1b PREMIUM 4 GASAHOL 1= 7 METHANOL <br />3 CHEMICAL PRODUCT a 95 UNKNOWN <br />2 WASTE <br />UNLEADED a 5 JET FUEL L_ <br />2 LEADED <br />O 1 BARE STEEL <br />2 STAINLESS STEEL <br />99 OTHER (DESCRIBE IN ITEM D. BELOW) <br />D. IF (A.1) IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C. A. S. # <br />IH- IONK C171\1STRIICTICIN <br />A. TYPE OF <br />1 DOUBLE WALL <br />3 SINGLE WALL WITH EXTERIOR LINER <br />V� 95 UNKNOWN <br />SYSTEM <br />2 SINGLE WALL <br />4 SECONDARY CONTAINMENT (VAULTED TANK) <br />99 OTHER <br />B. TANK <br />O 1 BARE STEEL <br />2 STAINLESS STEEL <br />[?--3 FIBERGLASS <br />4 STEEL CLAD W/ FIBERGLASS REINFORCED PLASTIC <br />MATERIAL <br />5 CONCRETE <br />6 POLYVINYL CHLORIDE <br />7 ALUMINUM <br />8 1009% METHANOL COMPATIBLE W/FRP <br />(Primary Tank) <br />9 BRONZE <br />10 GALVANIZED STEEL <br />95 UNKNOWN <br />99 OTHER <br />5 ALUMINUM <br />a 1 RUBBER LINED <br />2 ALKYO LINING <br />3 EPDXY LINING <br />4 PHENOLIC LINING <br />C. INTERIOR <br />D 5 GLASS LINING <br />[��6 UNLINED <br />95 UNKNOWN <br />99 OTHER <br />10 CATHODIC PROTECTION <br />IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? <br />YES _ NO_ <br />99 0OTHER <br />OTHER <br />D. CORROSION <br />O 1 POLYETHYLENE WRAP <br />2 COATING <br />El 3 VINYL WRAP <br />4 FIBERGLASS REINFORCED PLASTIC <br />PROTECTION <br />E::] 5 CATHODIC PROTECTION <br />a 91 NONE <br />F7 95 UNKNOWN <br />F-1 99 OTHER <br />E. SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED (YEAR) LqB, <br />OVERFILL PREVENTION EQUIPMENT INSTALLED (YEAR) <br />IV. r'II'IIVU w4ruNIVIA I IUN CIRCIF A IFARnVGrRnIINlnnR If ICIIkIncal-..ln ........ .,,,,. - <br />A. SYSTEM TYPE <br />A U <br />1 SUCTION <br />A U <br />2 PRESSURE A U <br />3 GRAVITY <br />A U 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 <br />A U 95 UNKNOWN A U 99 OTHER <br />C. MATERIAL AND <br />A U <br />1 BARE STEEL <br />A U <br />2 STAINLESS STEEL A U <br />3 POLYVINYL CHLORIDE (PVC) AM <br />4 FIBERGLASS PIPE <br />CORROSION <br />A U <br />5 ALUMINUM <br />A U <br />6 CONCRETE A U <br />7 STEEL W/ COATING <br />A U <br />6 1 METHANOL COMPATIBLE W/FRP <br />PROTECTION <br />A U <br />9 GALVANIZED STEEL <br />A U <br />10 CATHODIC PROTECTION <br />A U 95 UNKNOWN <br />A U <br />99 0OTHER <br />OTHER <br />D. LEAK DETECTION <br />a 1 <br />AUTOMATIC LINE LEAK <br />DETECTOR E 2 LINE TIGHTNESS <br />TESTING <br />IN I I IAL <br />� 99 OTHER <br />MONITORING <br />V. I ANK LtAK Ut I t(; I IUN <br />1 VISUAL CHECK F7 2 INVENTORY RECONCILIATION 3 VADOZE MONITORING 4 AUTOMATIC TANK GAUGING O 5 GROUNDWATER MONITORING <br />6 TANK TESTING ©�7 INTERSTITIALMONITORING 91 NONE 95 UNKNOWN F-1 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 a NO <br />THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT <br />APPLICANT'S NAME <br />(PRINTED & SIGNATURE)DATE <br />$ <br />Z •9L <br />LOCAL AGENCY USE ONLY THE STATE I.D. NUMBER IS COMPOSED OF THE FOUR NUMB RS BELOW <br />COUNTY # JURISDICTION # FACILITY # TANK # J" <br />STATE I.D.# 6; F-1 L] ETH- �T - <br />PERMIT NUMBER L�-P+ERMIT APPROVED BY/DATE PERMIT EXPIRATION (DATE <br />FORM B (7-91) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION • FORM A, UNLESS A CURRENT FORM A HAS B <br />01 0 <br />FOR00348-R5 <br />