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STATE OF CALIFORNIA ��yoV.�es STATE WATER RESOURCES CONTROL BOARD iyv� - UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ON ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE 8 TANK REMOVED D DBA OR FACILITY NAME WHERE TANK IS INSTALLED• 4,p r ,eV�ek 1 Al S �v I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A OWNER'S TANK I.D.• B. MANUFACTURED BY: C. DATE INSTALLED(MOADAY/YEAR) D. TANK CAPACITY IN GALLONS: 2 �© O II.TANK CONTENTS IF A-1 IS MARKED,COMPLETE ITEM C. A. EKI MOTOR VEHICLE FUEL ❑ 4 OIL B' ' C. I - REGULAR UNIFADED ❑ 3 DIESEL ❑ 6 AVIATION GAS ❑ 2 PETROLEUM E] 80 EMPTY Lrt!f{ i PRODUCT LJI 1b PREM9IM UNLEADED ❑ 4 GASAHOL ❑ 7 METHANOL ❑ 1C MIDGRADE UNLEADED ❑ 5 JETFUEL ❑ e M85 ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED O 99 OTHER(DESCRIBE IN ITEM D.BELOW) D. IF(A1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A S a 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 ❑yI 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 ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER C.INTERIOR ❑ I RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC UNING LINING OR ❑ 5 GLASS LINING ❑ 6 UNUNED ® 95 UNKNOWN ❑ 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES— NO— D.EXTERIOR 1 POLYETHYLENE WRAP ❑ 2 COATING 3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC CORROSION PROTECTION ❑ 5.CATHODIC PROTECTION ❑ 91 NONE Rk 95 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 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION A 1 SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND A401 BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A U 4 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL W/COATING A U B 100% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION ❑1 I cwmm U%LEAX 2 LME Twa M ❑3 Ceanaoo9s NTEAST ❑ EU 4 MMC UK ❑5 AVroM TIC RMP ❑ 99 oT eR 9ET w TE91N0 MCMTWIN9 LTAK XMCMR 9AInpWN Afflf V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK 2 MANUAL RECONCINVENTLIATION RY ❑ 3 VADOZE MONITORING ❑ 4 GAUGINGC TANK ❑5 GROUND WATER ❑ 6 TESTING ANNUALTANK ❑ 7 MONITORING INTERSTITIAL ❑ 6 SIH ❑ 9 TANK LY GING ❑10 MONTHLYTESTING TANK ❑ 95 UNKNOWN ❑99 OTHER VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) 1.ESTIMATED DATE LAST USED AY/YR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES � NO❑ 2^�L rq SOSTANCEREMAINING GALLONS WERTMATERIAL? THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF P JURY,AND TO THE BEST OF Y KNOWLEDGE,IS TRUE AND CORRECT TANK OWNER'S NAME DATE LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION N FACILITY ItaytoTANK x STATE I.D.# m FFTT I _LF EY PERMIT NUMBER PERMIT APPROVED BYIDATE PERMIT EXPIRATION DATE THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPUr'-ON-FORMA,UNLESS A CURRENT FORMA HAS BEEN FILED. FORM C MUST BE COMPLETED FOR INSTALLATIONS. THIS FORM SHOULD BE ACCOMPANIED BY A PLOT F\ RLE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE .RGROUND STORAGE TANK REGULATIONS FORM FORM B (6-95)