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�yov�cts STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD W m UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. 11 MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ON SITZ ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: v I. TANK DESCRIPTION COMPLETE ALL ITEMS - SPECIFY IF UNKNOWN A. OWNER'S TANK I. D. # 1 B. B. MANUFACTURED BY: UNKNOWN C. DATE INSTALLED (MO/DAYNEAR) UNKNOWN D. TANK CAPACITY IN GALLONS: 81000 II, TANK CONTENTS IF A-1 IS MARKED, COMPLETE ITEM C. A` n 1 MOTOR VEHICLE FUEL F74 OIL ' B. C ® 1a REGULAR UNLEADED ❑ 3 DIESEL ❑ 6 AVIATION GAS -1 2 PETROLEUM ❑ 80 EMPTY ® 1 PRODUCT ❑ 1b PREMIUM UNLEADED ❑ 4 GASAHOL ❑ 7 METHANOL ❑ 1c MIDGRADE UNLEADED ❑ 5 JET FUEL ❑ 8 M85 ❑ 3 CHEMICAL PRODUCT El 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED ❑ 99 OTHER (DESCRIBE IN ITEM 0. BELONI) D. IF (A.1) IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C. A. S. #: 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 X❑ 2 SINGLE WALL ❑ 4 SINGLE WALL IN A VAULT ❑ 99 OTHER B. TANK FX] 1 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 COMPATIBLEW/FRP (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER C. INTERIOR ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING LINING OR fx] 5 GLASS LINING ❑ 6 UNLINED ❑ 95 UNKNOWN 1?9(99 OTHER FRP AND STYRENE COATING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES — NO— A O95 UNKNOWN D. EXTERIOR F-1 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC CORROSION [:]5 CATHODIC PROTECTION ❑ 91 NONE 95 UNKNOWN ❑ 99 OTHER PROTECTION MONITORING LEAK DETECTOR SHUTDOWN E. SPILL AND OVERFILL, B2C. 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 U 1 SUCTION A(Uy PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A n5 UNKNOWN A U 99 OTHER C. MATERIAL AND A U 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 STEELW/COATING A U 8 100% METHANOL COMPATIBLEW/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A O95 UNKNOWN A U 99 OTHER D. LEAK DETECTION 1 MECHANICAL LINE LEAK 2 LINE TIGHTNESS 3 CONTINUOUS ❑ INTERSTITIAL 4 ELECTRONIC LINE ❑ 5 AUTOMATIC PUMP ❑ ❑ 99 OTHER DETECTOR TESTING MONITORING LEAK DETECTOR SHUTDOWN V. TANK LEAK DETECTION ❑ANNUAL 1 VISUAL CHECK ❑ 2 RECONCIL ATIONMANUAL INVENTORY F-13 MONITORING 9 VADOZE4 GAUGING AUTOMATIC TANK a 5 MON TORINGGROUND WATER ❑ 6 TESTINGTANK ❑ 7 CONMON INUOUCS INTERSTITIAL ❑ 8 SIR ❑ 9 WEEK LY MANUAL ❑ 10 MONTESTHLY TANK ❑ 95 UNKNOWN ❑ 99 OTHER VI. TANK CLOSURE INFORMATION (PERMANENT CLOSURE IN-PLACE) 1. ESTIMATED DATE LAST USED (MO/DAYNR) 2. ESTIMATED QUANTITY OF 3. WAS TANK FILLED WITH YES ❑ NO ❑ SUBSTANCE REMAINING GALLONS INERT MATERIAL 7 THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT TANK OWNER'S NAME ArA14M S�N�'I� ^ O �%� Ad -To oA DATE �' (PRINTED 8 SIGNATURE) /' ��/ I� LOCAL AGENCY USE ONLY THE STATE I.D. NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLIC"TION - 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 P -ILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE' -AGROUND STORAGE TANK REGULATIONS FORM 8 (6-95) COUNTY # JURISDICTION # FACILITY # TANK # (� STATE I.D:# m I I I O PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE p ^ THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLIC"TION - 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 P -ILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE' -AGROUND STORAGE TANK REGULATIONS FORM 8 (6-95)