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`01 STATE OF CALIFORNIA ��ew""e` 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 O 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION �i17 PERMANENTLY CL ED ON SIJE ONE ITEM r72 INTERIM PERMIT O 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE 1 8 TANK REMOVED OO DBA OR FACILITY NAME WHERE TANK IS INSTALLED: J SYY��'f0 It"T" I I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A OWNER'S TANK I.D.♦ B. MANUFACTURED BY: C. DATE INSTALLED(MQIDAY/YEAR) D. TANK CAPACITY IN GALLONS: II.TANK CONTENTS IFA-1 ISMARKED,C MPLETEITEMC. A ❑ 1 MOTOR VEHICLE FUEL 4 OIL B. C. 1e REGULAR UNLEADED O 3 DIESEL 0 6 AVIATION GAS 'I�2 PETROLEUM O 80 EMPTY ❑ 1 PRODUCT O 1e PREMIUMMUMEUNL ADHD O 4 GASAHOL ❑ 7 METHANOL 3 CHEMICALPRODUCT ❑ 95 UNKNOWN 2 WASTE 2 LEADED O 5 JOT ER(D B EMD , ,7 ❑ 89 OTHER(DESCRIBE IN ITEM D.BELO`A� D. IF(A7)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED W otcx C.A.S.N: 05 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 O 3 SINGLE WALL WITH EXTERIOR UNER ❑ 5 INTERNAL BLADDER SYSTEM ❑ 95 UNW40WN SYSTEM >e"2 SINGLE WALL ❑ 4 SINGLE WALL IN A VAULT ❑ 99 OTHER B. TANK 1 BARE STEEL O 2 STAINLESS STEEL F-1 3 FIBERGLASS O 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL O 5 CONCRETE F__j 6 POLYVINYL CHLORIDE O 7 ALUMINUM O B 100% METHANOL COMPATIBLE W/FRP (PLImery T"K) ❑ 9 BRONZE O 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER C.INTERIOR ❑ I RUBBER LINED F-] ALKYD LINING ❑ 3 EPDXY UNING 4 PHENOLIC LINING LINING OR ❑ 5 GLASS LINING 6 UNLINED O 95 UNKNOWN 99 OTHER COATING IS UNING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO_q D. F-11 POLYETHYLENE WRAP O 2 COATING F-13 VINYL WRAP O 4 FIBERGLASS REINFORCED PLASTIC CORROSION PROTECTION EJ ,�IyI/5 CATHODIC PROTECTION i�-�+91 NONE E�] 95 UNKNOWN ED 99 OTHER SPILL CONTAINMENTINSTIALLED R) OVERFILL PREVENTIO E UIPMENT INSTALLED(YEAR E.SPILL AND OVERFILL,BIC. ) 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 U 1 SUCTION 2 PRESSURE Alo 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION 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&I 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 ' MEc9 M UNE IFAK [:]2 MK TIGWKM 3 CMINUGUS INTEFmmu 4 S1 MMC UNE s AmoMAnc 2GMv ❑ GETEmmI n:snN6 MGN ING ttuTOST[croR ❑ sHulvGvnr ❑ 99 OTHER V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 MANUAL RECONCIUATIONORV ❑ 3 VOZEMAODNIITORING ❑ 4 GAUGING AUTOMATIC TANK ❑ TANK 5 GROUND MONITORING TESTING❑6 ANNUALTESTING ❑ T MONITORING INTERSTITIAL a 8 SIP ❑ 9 WE KLY MANUAL E]G TESTING 10 MONTHLY TANK ❑ 95 UNKNOWN ❑99 OTHER VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PUCE) 1.ESTIMATED DATE LAST USED(MO/DAYNR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES O 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 (PRNTLD 8 61GNATURE) LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW Fm COUNTY# JURISDICTION# FACILITY# TANK M LAY I STATE I.D.4 PERMIT NUMBER PERMIT APPROVED BYIDATE PERMIT EXPIRATION DATE ''.,f V 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 PLA" FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TA�N/K/R/E'GUULATIONS FORMS (6.95) NEW / - X /J(�✓7/K