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STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION -FORM B COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOS E ONE ITEM ❑ 2 INTERIM PERMIT F-14 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE 8 TANK REMOVED / DBA OR FACILITY NAME WHERE TANK IS INSTALLED: I/AMIJ1 RZOL L I. TANK DESCRIPTION COMPLETE ALL ITEMS— SPECIFY IF UNKNOWN A OWNER'S TANK I.D.# G(uK S. MANUFACTURED BY.- C. Y:C. DATE INSTALLED(MOIDAWYEAR) U D. TANK CAPACITY IN GALLONS: II.TANK CONTENTS IF A-1 IS MARKED.COMPLETE ITEM C. A t MOTOR VEHICLE FUEL ❑ s OIL B. C. ❑ ie REGULAR UNLEADED 3 DIESEL ❑ e AVIATION GAS ❑ 2 PETROLEUM ❑ 80 EMPTY ❑ 1 PRODUCT ❑ t: PREMIUM UNLEADED 6 GASAHOL ❑ 7 METHANOL ❑ ❑ ❑3 CHEMICAL PRODUCT 85 UNKNOWN 2 WASTE ❑❑ 2 MDEDE UNLEADED Q 99 JOTIER( (DESCFUELRIBE IN ITEMD.BELOW) D. IF(pl)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S.1: Ill. 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 BLADDER SYSTEM ❑ 95 UNKNOWN SYSTEM 2 SINGLE WALL ❑ 6 SINGLE WALL IN A VAULT ❑ 99 OTHER B. TANK I BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ # STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLEW/FRP (Primary Twk) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER C.INTERIOR ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ I PHENOLIC LINING LINING OR ❑ 5 GLASS LINING 6 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO— D.EXTERIOR ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ d FIBERGLASS REINFORCED PLASTIC CORROSION (p� PROTECTION E::] 5 CATHODIC PROTECTION Jai 91 NONE ❑95 UNKNOWN ❑ 99 OTHER E SPILL AND OVERFILL,810. 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 U 2 PRESSURE A U 3 GRAVITY A U d FLEXIBLEPIPING A U 99 OTHER B. CONSTRUCTION A (U1 SINGLE WALL A U 2 DOUBLE WALL A U 3 UNED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND AID 1 BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A U d FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL W/COATING A U 8 100% METHANOL COMPATIBLE WIFRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION o t lu!E rk UNE LEAI( 2 UNE iMiRNE53 3 w#ANLousFnEBE a BECIR UNE O Vf 5 A =PAu OETEffm ❑ TESTING MGNTGRING LGN IX7ECIOR 8l9 m ❑ 99 OTHER V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 RECONCAL ILIATION CILIATIONORY ❑ 3 VADOZEMONITORING ❑ A GAUGING AUTOMATIC TANK ❑ 5 MONITORING OUND TER ❑6 TESTING ❑ 7 MONITORING INTERSTITIAL ❑ B SIR ❑ 9 ANEK LAUGINGOY AL ❑10 TIESTINGY TANK ❑ 95 UNKNOWN ❑99 OTHER VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) 1.ESTIMA DATE LAST USED(MOIDAYNR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES NO SUBSTANCEREMAINING UN GALLONS INERT MATERIAL7 ❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT TANK OWNER'S NAMEDATE (PANTED A SIGNATURE) Wr_ I/1'Dw LOCAL AGENCY USE ONLYTHE STTATTEI.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW ( L COUNTY# JURISDICTION# FACILITY# ( N� STATE LD:# Fg,-? � / i� PERMIT NUMBER PERMIT APPROVED BYIDATE PERMIT EXPIRATION DATE D 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 PLAT ETAS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UN'—IGROUND STORAGE TANK REGULATIONS FORM B (6.95) `. r/ FORD04&"