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1 ' rya+"c¢a `+ STATE OFCAUFORNIA Mw c'S 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 O ONE REM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE yl B TANK REMOVED a DBA OR FACILITY NAME WHERE TANK IS INSTALLED: CO S. I. TANK DESCRIPTION COMPLETE ALL ITEMS— SPECIFY IF UNKN A OWNER'S TANK I.D.f 4 1 S. MANUFACTURED BY: ( A C. DATE INSTALLED(MOIDAYNEAR) --R D. TANK CAPACITY IN GALLONS: O II.TANK CONTENTS IF A-1 IS MARKED,COMPLETE ITEM C. p ❑ 1 MOTOR VEHICLE FUEL '�4 OIL B. C. Ia REGUTAR UNLEADED ❑ 3 DIESEL E] 6 AVIATION GAS ❑ 2 PETROLEUM ❑ 80 EMPTY ❑ I PRODUCT ❑ 1b PREMIUM UNLEADED ❑ 4 JET FUEL [—] 7 METHANOL JET ❑ 1C Ma]GRAOE UNLEADED 5 FUEL ❑ 8 M65 ❑ 3 CHEMICAL PRODUCT ❑ 85 UNKNOWN 2 WASTE ❑ 2 LEADED El 99 OTHER(DESCRIBE M ITEM D.BELOW) D. IF(AI)IS NOT MARKED. ENTER NAME OF SUBSTANCE STORED Lu/g-S-rte 0 C.A.S.a III. TANK CONS UCTION 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 ❑ SINGLE WALL ❑ 4 SINGLE WALL IN A VAULT ❑ OTHER B. TANK ❑ I BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CUD N FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 ONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP (Primary Twit) ❑ 9 NZE ❑ 10 GALVANIZED STEEL ❑ 85 UNKNOWN ❑ 99 OTHER C.INTERIOR ❑ 1 RU\ER LINED ❑ 2 ALKYD LINING F] 3 EPDXY LINING ED4 PHENOLIC LINING LINING OR F75 GLANING ❑ 6 UNLINED 1:195 UNKNOWN E] 99 OTHER COATING IS UNING MAL COMPATIBLE WITH 100% METHANOL? YES_ NO— D.EXTERIOR ❑ 1 POLY E WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC CORROSION PROTECTION ❑ 5 CATHODICP OTECTION ❑ 91 NONE ❑95 UNKNOWN ❑ 99 OTHER E.SPILL AND OVERFILL,at. SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) DROP TUBE ES_ NO_ STRIKER PLATE YES_ NO DISPENSER CONTAINMENT YES_ NO IV.PIPING INFORMATION CIRCk A IF ABOVE GROUND OR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER S. CONSTRUCTION A U I SINGLE WALL A U Z DOUBLE WALL A U 3 LINED TRENCH A U 85 UNKNOWN A U 99 OTHER C. MATERIAL AND A U 1 BARE STEELA 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 N COATING A U 8 100% METHANOL COMPATIBLEW/PRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION I MECH 'l L UNE IFAS ❑ LHIE TKtlRNESS ❑3 CONINUW3 INRASTT& ❑A EIECTROMC UK ❑5 AW—C PUMP ❑ 99 OTHER CEIECTOB TE30Na MDMrG IEAa OtTEC/011 91Uf00WN V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 RECONCILIATIONORY ❑ 3 MAONNIITORING ❑ 4 GAUGING AUTOMATIC TANK ❑5 MON TORINGOUND TER ❑ TANK 6 TESTING ❑ 7 CONTOR U INTERSTITIAL El SIR ❑ 9 TANK LY MANUAL ❑10 MOTESTINGHLY TANK ❑ 95 UNKNOWN E:] 99 OTHER VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) 1.ESTID DATE LAST US (MOADAWYR) 2.ESTIMATED OUANTfTY OF �A1 3.WAS TANK FILLED WITH YES ❑ CV _ SUBSTAGE REMAINING VV GALLONS INERT MATERIAL? 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 (PRINTE)6 VGNATURET LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY k JURISDICTION a �-�---F�A�CILITY M TANK M STATE 04 � � 0 8 3 PERMIT NUMBER PERMIT APPROVED BYIDATE FERMIT EXPIRATION DATE 71 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"-RLE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE W^ERGROUND STORAGE TANK REGULATIONS FORM B (6-95) _/ fee FOR00]0 11 �(