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STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B e,; . , I COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY F-1 I NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION El7 PERMANENTLY EO/1N SITE Lr/1 ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 8 TEMPORARY TANK CLOSURE ® 8 TANK REMO DBA OR FACILITY NAME WHERE TANK IS INSTALLED: Zi11Sl I I u 1 1 L TANK DESCRIPTION COMPLETE ALL ITEMS— SPECIFY IF UNKNOWN 4/^-( B. MANUFACTURED BY: u((LL A. OWNER'S TANK I.D.t tAl / C. DATE INSTALLED(MOADAY/YEAR) Uulr_ D. TANK CAPACITY IN GALLONS: Ib 1500 II.TANK CONTENTS IF A-1 IS MARKED,COMPLETE ITEM C. O.B. to REGULAR UNLEADED 3 DIESEL ❑ 8 AVIATIONGAS 1 MOTOR VEHICLE FUEL ❑ 4 OIL p � 10 PREMMM UNLEADED 4 GASAHOL ❑ 7 METHANOL 2 PETROLEUM ❑ BO EMPTY 1 PRODUCT ❑ is MCGRADE UNLEADED ❑ 5 JET FUEL ❑ 8 M85 ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED ❑ 99 OTHER(DESCRIBE IN ITEM D.BELOM D. IF(AI)IS NOT MARKED. ENTER NAME OF SUBSTANCE STORED C.A.S.R: 111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES p B.AND C,AND ALL THAT APPLIES IN BOX D AND E ❑ 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR UNER ❑ 5 INTERNAL BLADDER SYSTEM ❑ 95 UNKNOWN A. TYPE OF ❑ 99 OTHER SYSTEM 2 SINGLE WALL ❑ 4 SINGLE WALL IN A VAULT 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS E] 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B. TANK MATERIAL 5 CONCRETE ❑ 8 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER C.INTERIOR ❑ I RUBBER UNED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING LINING OR ❑ 5 GLASS LINING ® 6 UNUNED ❑ 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 91 NONE ❑95 UNKNOWN ❑ 99 OTHER PROTECTION EDS CATHODIC PROTECTION 52 willNMENT INSTALLED(YEAR) OVERFlLL PREVENTION EOUIPM ISP INSTALLED(YEAR) E SPILL AND OVERFILL,BLD. 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 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 UNED 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 B 100% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER 1 aEGxWIGLL ME UAN 2 ONE 1IGIR n 3 WNnl omao0l 4 ELECmCMC LINE ❑5 AaTIC PUMP ❑ 99 OTHER D. LEAK DETECTION ❑ aET Vl ❑ TE3TNG ❑ MGNroam3 ❑ I,:Mc ODEcroR aMnoan+ V.TANK LEAK DETECTION Q 1 VISUAL CHECK ❑ 2 RECONCILIATION LIORV ❑ 3 MONOITORING ❑ 4 GAUGWG AUTOMATIC TANK ❑5 GROUNDWAMONTORINGTER ❑6 ANNUAL TANK ❑ 7 CONTINUOUS MONITORING INTERSTITIAL ❑ 8 SIR ❑ 9 WEETANK LY MANUAL ❑ 10 MO LY TANK ❑ g5 UNKNOWN ❑99 OTHER VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) 1.ESTIMATED DATE LAST USED(MC/DAYNI 2.ESTIMATED QUANTITY OF 7 3.WAS TANK FILLED WITH YES [:] NO SUBSTANCE REMAINING GALLONS IN MATERIAL 7 THIS FORM HAS BEEN COMPLETED UNDER PE OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT TANK OWNER'S NAME l p < DATE /'� /y� (PRINTED a SIGNATURE)J p 1 4 {'�f�}Y✓1.'Q�V I U / LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY R JURISDICTION t FACILITY R TANK# Ct STATE LD:# m PERMIT NUMBER PERMIT APPROVED BYIDATE PERMIT EXPI TION DATE k4-116-4 THIS FORM MUST BE ACCOMPANIED BY A PERMIT APP ION-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. � .1 C MUST BE COMPLETED FOR INSTALLATIONS.THIS FORM SHOULD BE ACCOMPANIED BY A PLOT�. FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING III ERGROUND STORAGE TANK REGULATIONS FORM 8 (6-95)