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a `� tldW dCtld STATE OF CAUFORNIA J STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B I COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOS ONE REM ❑ 2 INTERIM PERMIT F-14 AMENDED PERMITS` ❑ 6 TEMPORARY TANK CLOSURE 8 TANK REMOVED C DBA OR FACILITY NAME WHERE TANK IS INSTALLED: ° L.' I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A OWNER'S TANK I.0.a B. MANUFACTURED BY: ��,I �7 C. DATE INSTALLED(MOIDAYNEAR) J D. TANK CAPACITY IN GALLONS: II.TANK CONTENTS IF A-1 IS MARKED,COMPLETE ITEM C. A ❑ 1 MOTOR VEHICLE FUEL �4 OIL B. C. 1a REGULAR UNLEADED [_] 3 DIESEL ❑ 6 AVIATIONGAS ❑ 2 PETROLEUM ❑ 80 EMPTY ❑ 1 PRODUCT ❑ 1D PREMIUM UNLEADED ❑ 4 GASAHOL [:j7 METHANOL ❑ E:]1c MIDGRPDE UNLEADED ❑ 5 JET FUEL B M85 ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN 2 WASTE ❑ 2 LEADED ❑ 99 OTHER PESCRIBEIN ITEM D.BT9AYn D. IF(A1)IS NOT MARKED. ENTER NAME OF SUBSTANCE STORED C.A S.k 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 ❑ I DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR UNER ❑ 5 INTERNAL BUDDER 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 (PdRry T-10 ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER C INTERIOR ❑ i RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY UNING ❑ 4 PHENOLIC LINING LINING OR ❑ 5 GLASS LINING ❑ 6 UNLINED 00 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 CORROSIONBl NONE r�I 95 UNKNOWN E] 99 OTHER PROTECTION ❑ 5 CATHODIC PROTECTION ❑ ycx SPILLCONTAINMENT INSTALLED(YEAR) OVERFILLPREVENII EOUIPMENTINSTALLED(YEAR) E SPILL AND OVERFILL,OTIC. DROP TUSE 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 U 1 SUCTION A U 2 PRESSURE A ZU3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION A U ' SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND AQ 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 STEEL W/COATING A U 8 1(10% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER 1 ME04NMAL LONE L"m 2 LNC TGXT M 3 wNRIaw15 NIFP51111AL 4 ELECiRCMC UNE S AIRCMATC PAP 99 OTHER D. LEAK DETECTION ❑ oEl am ❑ TEsnN3 ❑ LKNTDRnN ❑ ITAN oETEDroR ❑ auToovm ❑ V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 RECONCILIATION CILIATIONORY ❑ 3 MONITORING ❑ 4 GAUGING AUTOMATIC TANK ❑5 GROUNDWATER ❑6 TTEESTINGTANK ❑ 7 MONITORING CONTINUOUS INTERSTITIAL ❑ 8 SIR ❑ 9 TANK GAUNGING� ❑10 TESTINGY TANK 95 UNKNOWN ❑99 OTHER VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) 1.ESTIMATED DATE LAST U (MC/DAWYR) 2.ESTIMATED QUANTITY OF4 3.WAS TANK FILLEDA TH YES NO❑ _ SUBSTANC:REMAINING V GALLONS INERT MATERIAL? THIS FORM HAS BEEN COMPLETED UNDER PENALTY O E URY,AND TO THE BEST O;ht KNOWLEDGE,IS TRUE AND CORRECT TANK OWNERS NAME TE (PRINTED a SNWANR LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY k JURISDICTION k FACILITY♦ TANK k EPERMITNUMBEF TE I.D.# mLL PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE RM C MUST BE D FOR THIS FORM MUSTSHOULD BE ACCOMPANIED BYYAA PLOT IT APPLICATION *' FILE FTHIS FORM ORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNLESS A CURRENT FORM A HAS BEEN FILED. i ND RGROUND STORAGEE TANK REGULATIONS THIS �G FORM B (6.95) / 3 I - -0 2/ 'e C�S''W t,��I.A.i'4R� y,�, (..1 L> Iff///111