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STATE OF CALIFORNIA a 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 ❑ 2 INTERIM PERMIT F-14 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: sib 5. CZVFF p.r- I. TANK DESCRIPTION C MPLETE ALL ITEMS- SPECIFY IF UNKNOWN A OWNER'S TANK I.D.A IVS. MANUFACTURED BY: AadpW C. DATE INSTALLED(MOIDAYNEAR) ' 90 D. TANK CAPACITY IN GALLONS:S U II.TANK CONTENTS IF A-1 IS MARKED,COMPLETE ITEM C. A ❑ 1 MOTOR VEHICLE FUELd OIL B. C ie REGULAR UNLEADED ❑ 3 DIESEL ❑ 6 AVIATION GAS ❑ 2 PETROLEUM ❑ EMPTY 1 PRODUCT 1-1 :lbPREMIUM UNLEADED ❑ 4 GASAHOL ❑ 7 METHANOL ❑ 3 CHEMICALPRODUCT ❑ 95 UNKNOWN 2 WASTE ❑ 1C MIDGRADE UNLEADED 5 JET FUEL ❑ 8 M85 ❑ 2 LEADED 99 OTHER(DESCRIBE M ITEM D.BELOW) D. IF(Al)ISNOT MARKED, ENTER NAME OFSUBSTANCE STORED oT 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 SYSTEM/6 TS.� 2 SINGLE WALL F-14 SINGLE WALL IN A VAULT ❑ 99 OTHER B. TANK 1�1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD N FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ B 100% METHANOL COMPATIBLE W/FRP (Primary TmW ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER C.INTERIOR ❑ 1 RUBBER LINED ❑r�\2Q ALKYD LINING r-13 EPDXY LINING ❑ 4 PHENOLIC LINING LINING OR F-1u 5 GLASS LINING UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO— D.EXTERIOR ❑ 1 POLYETHYLENE WRAP Q 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC CORROSION PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE UNKNOWN ❑ 99 OTHER E.SPILL AND OVERFILL,MC. SPILL CONTAINMENT INSTALLED(YEAR) O RFILL PREVENTION EQUIPMENT INSTALLLLED(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 A U 2 PRESSURE AlUd GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION 1 SINGLE WALL A U 2DOUBLE 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,�UE�3 POLYVINYL CHLORIDE(PVC)A U 4 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 6 CONCRETE A V 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 MECIWflUL ME 2 M LEAIt TBxnEsS CCNRHUCCS AnERfir L MMC UNE m TIC PW@ CEI w ❑ 1E51W9 ❑3 MDMTMIW ❑4 EUm OETECmR ❑5 AvtN l ❑ 99 OTHER V.TANK LEAK DETECTION q ❑ 1 VISUAL CHECK 1_7 2 RECONCILIATIONNUAL ORY F] 3 MONIITORING OZE E] 4 GAUGING AUTOMATIC TANK [—] 5 GROUND MON TORING�R 6 TANK TESTING ❑ 7 MONITORING INTERSTITIAL ❑ 8 SIR ❑ 9 WEEKLY MANUAL ❑10 MONTHLYTESTING TANK ❑ 95 UNKNOWN 99 OTHER VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) 1.ESTIMATED DAT ED YNR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES NO SUBSTANCE REMAINING GALLONS INERT MATERIAL 7 ❑ 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 6 SIGNATURE) LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY# TANK# STATE I.Dl PERMIT NUMBER PIERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE 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 PI VILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE `.RGROUNO STORAGE TANK REGULATIONS FORM B (6-95) `i