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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 CLOSED ON SITE ONE ITEM E-] 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 8 TEMPORARY TANK CLOSURE R8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: lD5 („) I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A OWNERS TANK I.D.N B. MANUFACTURED BY: C. DATE INSTALLED(MO/DAYNEAR) } [; D. TANK CAPACITY IN GALLONS: �91 OU A IL TANK CONTENTS IF A-1 IS MARKED,COMPLETE ITEM C. A Co 1 MOTOR VEHICLE FUEL ❑ 4 OIL a C. to A LAN UNLEADED ❑ 3 DIESEL ❑ 8 AVIATION GAS 1D PREMRIM UNLEADED ❑ 6 GASAHOL ❑ 7 METHANOL ❑ 2 PETROLEUM ❑ BD EMPTY ❑ 1 PRODUCT 1c NOGPADE UNLEADED nI`� 5 JET FUEL ❑ 8 M ❑ 3 CHEMICAL PROOUCT ❑ 95 UNKNOWN ❑ 2 WASTE BS 2 LEADED L_.J 99 OTHER(DESCRIBE IN ITEM D.BELDYO D. IF(AI)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A S.e: 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 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 5 INTERNAL BLADDER SYSTEM ❑ 95 UNKNOWN SYSTEM 2 SINGLE WALL ❑ 4 SINGLE WALL N A VAULT ❑ 99 OTHER B. TANK rl I BARE STEEL ❑ 2 STAINLESS STEEL 253 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 8 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 10D% METHANOL COMPATBLE W/FRP M*MY To) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER C.INTERIOR ❑ I RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING LINING OR ❑ 5 GLASS LINING ❑ 8 UNLINED 95 UNKNOWN ❑ 99 OTHER COATING IS LINING MATERNAL COMPATIBLE WITH 100%METHANOL7 YES_ NO_ D.EXTERIOIONR ❑ 1 POLYETHYLENE WRAP [—] 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC CORROS PROTECTION El 5 CATHODIC PROTECTION ❑ Bi NONE 12K UNKNOWN ❑ 98 OTHER E.SPILL AND OVERFILL,8M, SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) DROPTUBE YES NO_ STRIKERPLATE 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 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLEPIPING A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL A k12 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 9 POLYVINYL CHLORIDE(PVC)A�4 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 8 CONCRETE A U 7 STEEL W/COATING A U 8 100%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 MFCYMat LAE MAK 2 IRE TnxllEsa 3 CmRNNws RNTERsrrML 4 BEC C 121E s AuralwTN Par ❑ ❑ E3 N9 ❑ IX.TDRNG ❑ �R ❑ 9M WAM ❑ 99 MER V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 TANK RECONCILIATION MONITORING ❑ 3 MOTORING ❑ 4 GAUGING AUTOMATIC TANK ❑5 MONTORINGWATER ❑ 8 TESTING ❑ 7 CONTINMONITUOUS INTERSTITIAL ❑RING8 SIR ❑ 9 SETANK GAUGINGNAL ❑10 NINGY TANK ❑ 95 UNKNOWN ❑99 OTHER VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) 1.ESTIMATED DALAST U (MO/DAY/YR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH SUBSTANCE REMAINING �' GALLONS INERT MATERIAL? YES ❑ NO THIS FORM HAS SEEN COMPLETED UNDER PENALTY OF PERJUR O TH E T OF MY KNOWLEDGE,IS TRUEAND CORRECT TANK OWNERS NAME (PRINTED&SIGNATURE) LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NU RS BELOW COUNTY N JURISDICTION K FACILITY A TANK 8 Q7 STATE I.D:# m = LLzia-,sl PERMIT NUMBER PERMIT APPROVED BYIDATE PERMIT EXPIRATION DA THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORMA,UNLESS A CURRENT FORM A HAS BEEN FILED. FORM C MUST BE COMPLETE FOR IN ALLATON .THIS FORM SHOULD BE ACCOMPANIED BY A PLOT PI FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE' -RGROUND STORAGE ANK REGULATIONS FORM 0 (8-95) 1.0/ _