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J STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD M1'; UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B "�� LL =� COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ T PERMANENTLY CLOSED ON SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED O DBA OR FACILITY NAME WHERE TANK IS INSTALLED: 'I'D C-WAC I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A OWNER'S TANK I.D.# MANUFACTURED BY: 4WD 4�, C. DATE INSTALLED(MOMAYNEAR) D. TANK CAPACITY IN GALLONS: /Q.(J� II.TANK CONTENTS IFA-1 IS MARKED,COMPLETE ITEM C. A MOTOR VEHICLE FUEL ❑ 4 OIL B. C. 1a flEGULM UNIEADFD 3 DIESEL ❑ 6 AVIATION GAS ❑ 2 PETROLEUM ❑ BO EMPTY E!f(1 PRODUCT ❑ 1D PREMIUM UNLEADED 4 GASAHOL ❑ T METHANOL ❑ 3 CHEMICALPRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 1c MIDGRADE UNLEADED 5 JET FUEL ❑ 8 MW ❑ 2 LEADED 89 OTHER(DESCRIBE M ITEM D.BELOW) D. IF(AI)IS NOT MARKED. ENTER NAME OFSUBSTANCE STORED C.A.S.#: 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 LINER ❑ 5 INTERNAL BLADDER SYSTEM ❑ 95 UNKNOWN SYSTEM IN 2 SINGLE WALL ❑ 4 SINGLE WALL IN A VAULT ❑ 99 OTHER B. TANK eg,1 BARE STEEL Q 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD Wl FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ l ALUMINUM ❑ 8 100% METHANOL COMPATIBLE WIFRP (PAY T-10 ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER C.INTERIOR ❑ 1 RUBBER UNED ❑ 2 ALKYD LINING ❑ 3 EPDXY UNING 4 PHENOLIC LINING LINING OR ❑ 5 GLASS LINING IN X a UNUNED ❑ 95 UNKNOWN ❑ 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO— D.EXTERIOR O 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC CORROSION PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE ❑ 95 UNKNOWN ® 99 OTHER 7 E.SPILL AND OVERFILL,etc. SPILL CONTAINMENT INSTALLED(YEAH) 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 AL72 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 T STEEL W/COATING A U 8 100% METHANOL COMPATIBLE WffRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION ALVIIS UNKNOWN A U 99 OTHER D. LEAK DETECTION VwcxuAUL UNE(FAIL 2 U- TMxrrASs 3 co#r S IMRESPIAl 4 c UK 5 AUT9 m mw DETECTOR TESTN9 ❑ LgN}ORNO ❑ ELEc9aIS IFAK DETECTOR ❑ SHU1001TN ❑ 99 OTHER V.TANK LEAK DETECTION ,7 TA!NK] ❑ 1 VISUAL CHECK 15M 2 RECONCAL ILIATION CILATIONORY ❑ 3 MAONNIITORING ZE ❑ 4 GAUGNGIC TANK ❑5 MONTORIN(OUND WATER 8 TE�NGLG ❑ T MNTINU U INTERSTITIAL ILFJ-1 B SIR ❑ 9 WEETANKLY MANUAL ❑ 10 MOTESTHLY TANK ❑ 95 UNKNOWN ❑99 OTHER NG VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) 1.ESTIMATED DATE LAST USED(MOIDAYNR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES ❑ NO SUBSTANCE REMAINING GALLONS INERTMATERIAL7 THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT TANK OWNERS NAME DATE (PRINTEpi6WNATURE7 LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY# TANK# LjIVjr 67- STATE LD:# m / 9 6 L PERMIT NUMBER PERMIT APPROVED BYIDATE PERMIT EXPIRATION DATE THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORMA,UNLESS A CURRENT FORMA HAS BEEN FILED. FORM C MUST BE COMPLETED FOR INSTALLATIONS. THIS FORM SHOULD BE ACCOMPANIED BY A PLOT P' FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THF 'ERGROUND STORAGE TANK REGULATIONS FORMS (6-95) %—/ ��