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`/ 'WaveSTATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD a 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 ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: -5✓ p ewc Zl 1. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A OWNER'S TANK I.D.K B. MANUFACTURED BY: `. K C. DATE INSTALLED(MOIDAYNEAR) O✓ D. TANK CAPACITY IN GALLONS: AlcjyL.� II.TANK CONTENTS IF A-1 IS MARKED,COMPLETE ITEM C. / A. 1 MOTOR VEHICLE FUEL ❑ 4 OIL B./A C. 1A REGUWi UNLEADED ❑ 3 DIESEL ❑ 8 AAATIONGAS ❑ 1C PREMIUM UNLEADED E] 4 GASAHOL ❑ 7 METHANOL ❑ 2 PETROLEUM ❑ 00 EMPTY 1 PRODUCT 7c MOGRADE UNLEADED 5 JET FUEL ❑ 8 M65 ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN 2 WASTE 2 LEADED L_j99 OTHER(DESCRIBE IN REM D.B0.0Y1) D. IF(Ai)IS NOT MARKED, ENTER NAME OF SUBSTAGE STORED C.A S.A: 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 ❑ 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 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 COMPATBLE W/FRP (Pll-'YTMK) ❑ 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-A METHANOL? YES_ NO— D.EXTERIOR ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC CORROSION 1 _ PROTECTION 1_I a CATHODIC PROTECTION ❑ 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 APPUCABLE A. SYSTEM TYPE A 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION A 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 8 100% METHANOL COMPATIBLE WIFRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A 1>95 UNKNOWN A U 99 OTHER D. LEAK DETECTION E]' M:CNAMCAL UNE LEAK ❑2 UNE TIGNTNESG ❑3 CCNRNUW3 MENS^11AL ❑4 u mlc NE ED 5 AMMIC MW DETECTOR TE39NG MGMTGRIN6 LMK DETECTOR 9XIIGGWN ❑ 99 OTHER V.TANK LEAK DETECTION �q F-11 VIBUAL CHECK I2(?r RECONCILIATION MANUALINVENTORY CO CILATIONORV ❑ 3 MONITORING VAE ❑ 4 GAUGING AUTOMATIC TANK E::]5 MONTORINGGROUND TER 6 �nNLGTANK ❑ 7 MONITORING INTERSTITIAL E] 8 SIR ❑ 9 WEEKLY MANUAL ❑10 MONTHLY TANK ❑ 95 UNKNOWN 99 OTTER TANK AUGING TESTING VL TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) 1.ESTIMATED DATE T US D(MO/DAY/YR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES ❑ NO fj SUBSTANCE REMAINING O GALLONS INERT MATERIAL THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT TANK OWNER'S NAME DATE (PRINTED d VGNATURE) LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY @ JURISDICTION M FACILITY @ TANK @ STATE LD:# L-i I PERMIT NUMBER IIE14MIT APPROVED BY/DATE PERMT EXPIRATION DATE I z 14 R(- THIS FORM MUST BEACCOMPANIED BYAPERMIT APPUC#^)N-FORM A,UNLESS A CURRENT FORMA HAS BEEN FILED. FORM C MUST BE COMPLETED F R INSTALLATIONS. THIS FORM SHOULD BE ACCOMPANIED BY A PLOT PL 'LE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE T AGROUND STORAGE TANK REGULATIONS FORM B (6-95) ��