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STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD c~a 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 114 q ONE ITEM F-1AM 2 INTERIM PERMIT ❑ 4 ENDED PERMIT O 6 TEMPORARY TANK CLOSURE E:18 TANK REMOVED V DBA OR FACILITY NAME WHERE TANK IS INSTALLED: �L L �c. T_ ®I. TANK DESCRIPTION COMPLETE ALL ITEMS– SPECIFY IF UNKNOWN 7 A. OWNER'S TANK I.D.Y B. MANUFACTURED BY: C. DATE INSTALLED(MCrDAV/VEAR) ( D. TANK CAPACITY IN GALLONS: II.TANK CONTENTS IF A-1 IS MARKED,COMPLETE ITEM C. A. 1 MOTOR VEHICLE FUEL ❑ 4 CIL B. C. la REGIIUR UNLEADED3 DIESEL E] 6 AVIATION GAS ❑ 2 PETROLEUM E:] 80 EMPTY 1 PRODUCT ❑ ib PREMNM UNLEADED 4 GASAHOL ❑ ' METHANOL ❑ Ic MKIORADE UNEADED E::] 5 JET FUEL ❑ 8 M85 F-1 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED ❑ 99 OTHER(DESCRIBE N REAM D.W-OW) D. IF(Al)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.&#: 111. 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 #4TERNAL BLADDER SYSTEM ❑ 95 UNKNOWN SYSTEM ❑ 2 SINGLE WALL ❑ 4 SINGLE WALL IN A VAULT ❑ 99 OTHER B. TANK ❑ 1 BARE STEEL ❑ 2 STAINLESS STEEL FAOXFIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATBLE W/FRP (Primary Twk) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER C.INTERIOR ❑ 1 RUBBER LINED ALKYO LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC UNING LINING OR ❑ 5 GLASS LINING 8 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER COATING IS UNING MATERIAL COMPATIBLE WITH 100% METHANOL? YES— NO— D.EXTERIOR ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC CORROSION PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE ❑ 95 UNKNOWN ❑ W OTHER E.SPILL AND OVERFILL,ILC. SPILL CONTAINMENT INSTBkLED(YEAR) OVERFILL PREyGNTION EOUIPMENT INSTALLED(YEAR) DROP TUBE YES— NO_ IKEA PLATE YES_✓NO_ DISPENSER CONTAINMENT Y S NO IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND,BOTH IF APPUCABLE A. SYSTEM TYPE A U 1 SUCTION AU PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL A U DOUBLE 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 U 3 POLYVINYL CHLORIDE(PVC) FIBERGLASS PIPE CORROSION A U 5 ALU INUM A U 6 CONCRETE A U 7 STEEL W/COATING A U 8 100% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 LVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION 1EQ1'' 'x Le1E UA ❑2 ME TCKm>:ss mxluAws WTEAdi11UL [:]4 BEcmavlc uxE s AuroKlrK PUIi OETECfOR TLsnxG IlaNfalUxG rEAx rlElecTon ❑ 9Nroovm ❑ 99 onlFn V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 RECOMANU CIUAT014 AL INVENTORY ❑ 3 MAODNOITORING 4 GALA TAUTOMATIC TANK ❑5 GROUND MONITORING ❑8 TESTING MOONTINOURO INTERSTITIAL ❑ING 8 Sifl ❑ e WE KGA=AL ❑10 MONTHLY NTHLY TANK ❑ 95 UNKNOWN ❑99 OTHER TtNG VL TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PUCE) 1.ESTIMATED DATE LAST USED(MO/DAY/YR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES ❑ NO❑ SUBSTANCE REMAINING GALLONS INERTMATERIAL7 THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF P9,11KRY,A)V7,1 THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT TgNK OWNER'S NA DATE (PRINTFDd51GNATUR � /4z/ 4e ^ 11 I�V LOCAL AGENCY USE ONLY THE STATE I.D.NUMBE SCO OFTHE FOUR NUMBERS BELOW 3` COUNTY# URISDI ON# FACILITY# TANK# i STATE I.D:# m PERMIT NUMBER PERMIT APPROVED BVIOATE PERMIT EXPIMTION 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 PL'"' RLE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE''-IRGROUND STORAGE TANK REGULATIONS FORM B (&95) `� `�