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� STATE OF CALIFORNIA .. 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 CLOSED ONSITE ONE ITEM ❑ 2 INTERIM PERMIT Q 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ® B TANK REMOVED DBAOR FACILITY NAME WHERE TANK IS INSTALLED: /Ie.+hkr ptb= f 1. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A OWNER'S TANK I.D.M /K4lk B. MANUFACTURED BY: C. DATE INSTALLED(MO/DAYNEAR) P-�"t'V D. TANK CAPACITY IN GALLONS: LIVVVfV II.TANK CONTENTS IF A-1 1S MARKED,COMPLETEITEMITEM C. A 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C. n-� 1a REGULAR UNLEADED ❑ 3 DIESEL ❑ 6 AWATIONGAS 2 PETROLEUM ❑ 80 EMPTY 1 PRODUCT 12�ib PREMNM UNLEADED ❑ 4 GASNOL ❑ 7 METHANOL ❑ lc MIDGRADE UNLEADED 5 JET FUEL ❑ 8 M85 ❑ 3 CHEMICALPRODUCT ❑ 9S UNIPIOVM ❑l 2 WA((STTE .�A,Iy❑ 2 LEADED 89 OTHER(DESCRIBE IN REM D.eE10Y✓) D. IF(At)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED 14AIUS-e4./ fAil — C.AS.M: 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 UNER ❑ 5 INTERNAL BLADDER SYSTEM ❑ 95 UNKNOWN SYSTEM13- 2 SINGLE WALL ❑ 4 SINGLE WALL IN A VAULT ❑ 99 OTHER B. TANK z 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ B POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP (Plimmy T-k) ❑ 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 1 6 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 10D% METHANOL? YES_ NO— D.EXTERIOR ❑ 1 POLYETHYLENE WRAP O 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC CORROSION ��ff PROTECTION E::] 5 CATHODIC PROTECTION IN 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 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLEPIPING A U 99 OTHER B. CONSTRUCTION 1 SINGLE WALL A U 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 B 100% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION ❑1 �M LANE LEAK ❑2 LANE 71x8 W ❑3 ca+lNuous wrERsnTlu ❑4 EtECIRGNG uN ❑s Al1foMA7K:wrs ❑ 99 OTHER bEISC TEflRXi MON? m LEAK9(=t 9NIWWN V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 RECONCILIATIONTIORV ❑ 3 ❑ 4 AUTOMATIC TANK [:]5 �R ❑ 6 TNK MONITORING GAUGING MONITORING TESTING ❑ 7 CONTINUOUS INTERSTITIAL ❑ 8 SIR ❑ 9 WEEK LY MANUAL ❑ 10 MOSNTHLY TING TANK E::] 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) 1.EST AT•Er0 DATE wi)SED(MO/DAV/YR) 2.SUBSTANCE REMAININGTED QUANTITY F GALLONS 3 WAINERT MATERIALTANK FILLED ?H YES ❑ NO�( THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT TANK OWNER'S NAME / A DATE (PRINTEDA6IGNATUPE7 AA� 11 11_'7 LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW L COUNTY# JURISDICTION 9 FACILITY# TANK# STATE I.D.# No 1 PERMIT NUMBER PERMIT APPROVED BYLDATE PERMIT EXPIRATION DATE 8 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 PLA? E THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UE' GROUND STORAGE TANK REGULATIONS FORMS (6-95) we FOR00346117