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STATE OF CALIFORNIA �� s STATE WATER RESOURCES CONTROL BOARD i r� +g UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM B - , 1 COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CL ON ITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED �PERMIT n❑ 6 TEMPORARY TANK CLOSURE © B TANK REMOVED DBAOR FACILITY NAME WHERE TANK IS INSTALLED: Z4081L$( (_1C(b -Fo-) 1. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A OWNER'S TANK I.D. B. MANUFACTURED BY: C. DATE INSTALLED(MOIDAYNEAR) UL( D. TANK CAPACITY IN GALLONS: IO 11.TANK CONTENTS IF A-1 IS MARKED,COMPLETE ITEM C. A [ 1 MOTOR VEHICLE FUEL ❑ 4 OIL S. C, I%A tE REGULAR UNLEADED n� 3 DIESEL [:] 6 AVIATIONGAS ❑ 2 PETROLEUM E] 80 EMPTY © 1 PRODUCT 1b PREMIUM UNLEADED u 4 GASAHOL ❑ 7 METHANOL ❑ iC MIDGRADE UNLEADED ❑ 5 JETFUEL E:] 6 M85 ❑ 3 CHEMICAL PRODUCT ❑ B5 UNKNOWN El2 WASTE ❑ 2 LEADED ❑ 99 OTHER(DESCRIBE IN ITEM D.BELOM D. IF(A1)IS NOT MARKED. ENTER NAME OF SUBSTANCE 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 C� 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 ❑ B 100% METHANOL COMPATIBLE W/FRP (PrIm yTBRk) ❑ 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% METHANOL? YES_ NO— D.EXTERIOR ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC CORROSION PROTECTION ❑ 5 CAT140DICPROTECT10N 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 IFAPPUCABLE A. SYSTEM TYPE A U 1 SUCTION 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(D 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 W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION [—]I IEfJIN9oAL ME LEAK ❑2 SNE 11o1R W ❑3 COKIMUWS IMER9TIRAL [D 4 EILECIRp4C UNE O 5 urt�o mw ❑ 89 ODIQi oETE" TES uoNTarw,a lEA%9ETECTC9 V.TANK LEAK DETECTION ® 1 VISUAL CHECK ❑ 2 TANK MANUALVAOZE GROUND ANNUAL RECONCILIATION ORY ❑ 3 MONIITORING ❑ 4 GAUGING AUTOMATIC TANK ❑ 5 MONITORING TESTING❑41 TES ING ❑ 7 MON TORO INTERSTITIAL E] 8 SIR ❑ 9 TA KIGAUGAL 10 ING ❑ TE NTTINGY TANK ❑ 95 UNKNOWN ❑99 OTHER A.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) 1.ESTIMATED DATE LAST USED(MOIDAYNR) 2.ESTIMATED OUANTITY OF '7 3.WAS TANK FILLED WITH YES E] NO SUBSTANCE REMAINING GALLONS INERT MATERIAL? THIS FORM HAS BEEN COMPLETED UNDER PENAL OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT TANK OWNER'S NAMEDATE ttA r DATE LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY# TANK# I - STATE I.D.# p hl7 PERMIT NUMBER 'PERMIT APPROVED BYIDATE PERMIT EXPIRATION DATE i THIS FORM MUST BE ACCOMPANIED BY A PERMIT APP 'ION-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. - `4 C MUST BE COMPLETED FOR INSTALLATIONS. THIS FORM SHOULD BE ACCOMPANIED BY A PLOD. RLE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING T) iERGROUND STORAGE TANK REGULATIONS ^� FORM 8 (6.95)