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STATE OF CALIFORNIA \� STATE WATER RESOURCES CONTROL BOARD �`• c t' UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B "� e COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. " MARK ONLY Q.jR 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION O 7 PERMANENTLY CLOSED ON SITE ONE REM M1�Jj 2 INTERIM PERMIT O 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ B TANK REMOVED Pl DBA OR FACILITY NAME WHERE TANK IS INSTALLED: G0LJT4TT2_L( ^A -r' C/ I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A OWNER'S TANK I.D.K B. MANUFACTURED BY: 'rF-V5 /- C:) C. DATE INSTALLED(MOIDAYNEAR) 3w'-l7 D. TANK CAPACITY IN GALLONS: 2-O II.TANK CONTENTS IF A-1 IS MARKED,COMPLETE ITEM C. A. X, MOTOR VEHICLE FUEL 074 OIL B. C. 1a REGULAR UNLEADED ❑ 3 DIESEL ❑ 6 AVIATIONGAS ❑ 2 PETROLEUM BO EMPTY �1 PRODUCT ❑ ib PREMIUM UNLEADED ❑ 4 GASAHOL ❑ 7 METHANOL ❑ tc MIDGRADE UNLEADED ❑ 5 JETFUEL ❑ 8 M85 ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE O 2 LEADED ❑ 99 OTHER(DESCRIBE IN ITEM D.BELOW) D. IF(A1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S.0: 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 ICL I 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 JCJ T 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 COMPATIBLEW/FRP (PRnTY T„W ❑ 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 �8 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 4 FIBERGLASS REINFORCED PLASTIC CORROSION PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE ❑95 UNKNOWN ❑ 99 OTHER E.SPILL AND OVERFILL,etc. SPILL CONTAINMENTIIJSTALLED(YEAR) OVERFII L PliEVENTION EQUIPMENT INSTALLED(YEAR) DROP TUBE YES_L NO STRIKER PLATE VES�_ NO DISPENSER CONTAINMENT YEI NO IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION AID 2 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL AO2- 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 B CONCRETE A U 7 STEEL W/COATING A U 8 100% METHANOL COMPATIBLE WIFRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODICPROTECTION A U 95 UNKNOWN A(P99 OTHER 1 M CTOR ONE lFlJt E:l2 I1 9GNINESS 3 CONTINUOUS iNTEASTRIAL 4 FIECTRCNC MNE 5 A9TCMITIC PUAP D. LEAK DETECTION ❑ 6EIEcroR TEsnNo MCN'ITCRING LFM oElEcroR ❑ WLffCCW4 ❑ ss OTHER V.TANK LEAK DETECTION �VA ZEyj �1 VISUAL CHECK ❑ 2 RECONCILIATIONAL ORY ❑ 3 MONIITORING .A`"" 4 GAUGING IC TANK ❑5 MONITORINGGROUND TESTING❑8 TESTNGTANK 7 MONITORING INTERSTITIAL ❑ 8 SIR ❑ 9 WEETANKLY MANUAL ❑10 MONTHLY TANK ❑ 95 UNKNOWN ❑99 OTHER NG VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) 1.ESTIMATED DATE LAST USED(MO/DAY/YR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES ❑ NO❑ SUBSTANCE REMAINING GALLONS INERT MATERIAL? THIS FORM HAS BEEN COMPLETED UNDER PENALTY PF PERJ RY, ND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT TANK OWNER'S NAME DA� (PRINTEDd SIGN R A I � O LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS C POSED OF THE FOUR NUMBERS BELOW COUNTY M JURISDICTION k FACILITY M TANK* STATE I.D.# m = -V '71 PERMIT NUMBER PERMIT APPROVED BYA)ATE PERMIT EXPIRATION DATE THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLIC ATION-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 PI 9LE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE' 'RGROUND STORAGE TANK REGULATIONS FORM B (6-95) `/ VAW