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STATE OF CALIFORNIA 1.1/ STATE WATER RESOURCES CONTROL BOARD _ o 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 CL D TE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ,.y 6 TEMPORARY TANK CLOSURE S TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: eVJ VQ,K G I e"-A I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A. OWNERS TANK 1.D.# u K k- B. MANUFACTURED BY: C. DATE INSTALLED(MOrDAV/YEM) U4,J D. TANK CAPACITY IN GALLONS: .j II.TANK )yy CONTENTS IF A-1 IS MARKED,COMPLETE ITEM C. A 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C1:1 lA REGULAR UNLEADED 3 DIESEL ❑ 6 AVIATION GAS 2 PETROLEUM O SO EMPTY ❑ 1 PRODUCT ❑ ib PREMIUM UNLEADED 4 GASAHOL ❑ 7 METHANOL ❑ it MIDGRPDE UTAEADEO ❑ 5 JET FUEL S MSS ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED ❑ 99 OTHER(DESCRIBE N ITEM D.BELOW) D. IF(AI)IS NOT MARKED. ENTER NAME OF SUBSTANCE STORED C.A.S.N: 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 ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 5 INTERNAL BLADDER SYSTEM ❑ 95 UNKNOWN SYSTEM 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 ❑ S 100% METHANOL COMPATIBLE W/FRP (Primary Till ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER C.INTERIOR ❑ I RUBBER UNED ❑T 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOUC 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 CATHODIC PROTECTION [3(91 NONE 0 9 UNKNOWN ❑ 99 OTHER E SPILL AND OVERFILL,#10. SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EOUIPMENT 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 IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION A6)2 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION A I SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND A 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 S 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 ❑1IEa GAL M1E LFAK ❑2 ss ❑3coxTTN�UgIs ilEnsimu O e¢FC1Tu1E O s A Pwn ❑ 99 OTHER V.TANK LEAK DETECTION .VJ 1 VISUAL CHECK ❑ 2 MANRECONAL CILIATION CILIATIONORY ❑ 3 MONITORING ❑ 4 AUTOMATIC TANK ❑5 GROUND MONITORING ANNUALTANK ❑6 TESTING ❑ 7 NC�ONTINNITORINGUO INTERSTITIAL ❑ 6 SIR ❑ 9 TANEK GA=AL E:] 10 TESTINGMONTHLY TANK ❑ 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE INLACE) 1.ESTIMATED DATE LAST USED(MO/DAY/YR) 2.EsTimATE6OUANTlTY OF //_. 3.WAS TANK FILLED WITH YES ❑ NO,K SUBST CE REMAINING UU GALLONS INERTMATERIAL? THIS FORM HAS BEEN COMPLETED UNDER P OFJIERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT TANK OWNER'S NAME /ryL�{// 1 DATE�] (PRINTm 6 51GNATURE) Y`L L IIA fit.W1, C \ �+! VGA/�'�✓" (—7, LOCAL AGENCY USE ONLY THE STATE I.D.NU ER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY#463 TANK# GYJZ STATE I.D.# 151 C) 4.17 8 0 1510 Ile g Z li 112 fl-7 PERMIT NUMBER PERMIT APPROVED BVIDATE PERMITEXPIRATIN DATE AL b THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPUCA^^N-FORM A,UNLESS A CURRENT FORMA HAS BEEN FILED. FORM C MUST BE COMPLETED FOR INSTALLATIONS.THIS FORM SHOULD BE ACCOMPANIED BY A PLOT PL/ LE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE I' ?GROUND STORAGE TANK REGULATIONS FORM B (6-95) �� *mpI