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STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD ;yti g UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B 1 COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY IK 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION � 7 PERMANENTLY CLOSED SIT ONE ITEM El INTERIM PERMIT F-14 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE 8 TANKREMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: Ul I. TANK DESCRIPTION COMPLETE ALL ITEMS - SPECIFY IF UNKNOWN A OWNER'S TANK I. D. 0 / --- B. MANUFACTURED BY: F' -� i C. DATE INSTALLED (MO/DAYNEAR) !• D. TANK CAPACITY IN GALLONS: 1L. S II. TANK CONTENTS IF A-1 IS MARKED, COMPLETE ITEM C. A1 MOTOR VEHICLE FUEL F-]4 OIL W, MOT2 B. C to REGULAR UNLEADED ❑ 3 DIESEL F]6 AVIATION GAS ❑ PETROLEUM El 80 EMPTY PRODUCT ❑ 1b PREMIUM UNLEADED ❑ 4 GASAHOL ❑ 7 METHANOL ❑ 1c MIDGRADE UNLEADED ❑ 5 JET FUEL ❑ 8 M85 ❑ 3 CHEMICAL PRODUCT ❑ 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. #: 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 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 ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING LINING OR ❑ 5 GLASS LINING ❑ 6 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL 7 YES _ NO— A U D. EXTERIOR. ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP V4 FIBERGLASS REINFORCED PLASTIC CORROSION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER PROTECTION DETECTOR TESTING INO E. SPILL AND OVERFILL, etc. SPILL CONTAINMENT I DROP TUBE YES =AND TAL.LED (YEAR) OVERFILL P VENTION EQUIPMENT INSTALLED (YEAR) 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 1v 12 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL A Cl 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 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 STEEL W/ COATING A U 8 1DO% METHANOL CO�'}�ATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER _4 Q I' C D. LEAK DETECTION WC.ICAL UNE LEAK ❑ 2 LINE TIGHTNESS CONTINUOUS C TT""" INTERSTmAL ❑ 4 ELECTRONIC UNE 5 AU OMATIC PUMP ❑ 99 OTHER DETECTOR TESTING INO LEAK DETECTOR SHUTDOWN V TANK I FAK OFTFCTION VISUAL CHECK ❑ 2 MANUAL ORY ❑ 3 OZE M, 4 IC TANK ❑ 5 GROUND TER ❑ 6 ANNUAL RECONCILIATION MONIITORING GAUGING MONITORING TESTING INTERSTITIAL �?7 ❑ WEEKLYMANUAL 1:110 MONTINGY TANK El 95 UNKNOWN 8 SIR ❑ 9 F-199 OTHER MON TORONUS G T NK VI. TANK CLOSURE INFORMATION (PERMANENT CLOSURE IN-PLACE) 1, ESTIMATED DATE LAST USED (MO/DAY/YR) 2. ESTIMATED QUANTITY OF 10573. WAS TANK FILLED WITH YES ❑ NO SUBSTANCE REMAINING GALLONS INERT MATERAL 7 ' THIS FORM HAS BEEN COMPLETF_D UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT TANK OWNER'S NAME DATE (PRINTED 8 SIGNATURE) LOCAL AGENCY LISF ONLY THE STATE I.D. NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY k JURISDICTION a FACILITY # 00,3 144 TANK 0 D STATE I.D.# mI I A 3 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 PLAN. FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS FORM B (6-95) " Ddoe �, /4'�