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STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD %y ^'tom UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B , - 1 COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY <TANK CLOSURE �( B TANK REMOVED O DBA OR FACILITY NAME WHERE TANK IS INSTALLE � v �Y� I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A OWNERS TANK 1.D.# B. MANUFACTURED BY:VJV Al C. DATE INSTALLED(MO'DAY/YEAR) D. TANK CAPACITY IN GALLONS: 010,19 II.TANK CONTENTS IFA-115 MARKED.COMPLETE ITEM C. A, 1 MOTOR VEHICLE FUEL ❑ I OIL B. C. to REGULAP UNIFAOFD ❑ 3 DIESEL ❑ 6 AVIATIONGAS ❑ 2 PETROLEUM ❑ BO EMPTY �1 PRODUCT 1b PREMIUM UNLEADED ❑ 4 GASAHOL ❑ 7 METHANOL ❑ 1c MIDGRADE UNLEADED ❑ 5 JETFUEL ❑ 8 M85 ❑ 3 CHEMICALPRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED ❑ 99 OTHER(DESCRIBE IN ITEM D.BELOW) D. IF(A.1)IS NOT MARKED. ENTER NAME OF SUBSTANCE STORED C.A S.N 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 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 Lel I BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ B 100% METHANOL COMPATSLE W/FRP (PrimaryTwk) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER C.INTERIOR ❑ I RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING vLINING OR ❑ 5 GLASS LINING ❑ 6 UNUNED 1 95 UNKNOWN ❑ 99 OTHER r COATING IS LINING MATERIAL COMPATIBLE WITH 100116 METHANOL? YES_ NO— 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 E.SPILL AND OVERFILL,BIC. 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 U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION Alff I SINGLE WALL A U 2DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND Ao 1 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 STEELYWCOATING A U 8 100% METHANOL COMPATIBLEW/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION ❑❑1 ITECKAMdL UNE LEAN 2 TWTNESE C 3 N..ImB811IUL 4 DECm NE U5 AUro1u9C MW 9E ❑ 0011 lEUNE nw mowm 6 LUX aETECTOR 9iR1I001YN ❑ 99 O ER V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK 2 MANUAL INVENTORY ❑ 3 MAOOOZE NIITORING ❑ 4 AUTOMATGAUGING MONITORING TANK ❑5 GROUND WATER ❑ 6 ANNUALTESTING ❑ 7 MONITORING INTERSTITIAL 8 SIR ❑ 9 TA KIGAUGANGAL ❑10 MOTHLY TANK ❑ 95 UNKNOWN ❑99 OTHER TESNG VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE M-PLACE) 1.ESTIMATED DATE LAST USED( O/DAWYR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES NO❑ L, SUBSTANCE REMAINING GALLONS INERT MATERIAL? THIS FORM HAS BEEN CO_fj5E UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT TANK OWNER'S NAME D. � DATE(PRINr / J TANKmaNER'S N 1 LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE iOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY# TANK# STATE I.D.# m PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE 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 PI "" RLE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE-'-'�RGROUND STORAGE TANK REGULATIONS FORM B (695) `! a i t,W zt�>*-,