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STATE OF CALIFORNIA = STATE WATER RESOURCES CONTROL BOARD "� a UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B �-y COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM MARK ONLY L>g 1 NEW PERMIT 3 RENEWAL PERMIT E] E] :CZFo 5 CHANGE OF INFORMATION 7 PERMANENTLY ONSITE ONE ITEM 2 INTERIM PERMIT 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ B TANK REMCIYO DBA OR FACILITY NAME WHERE TANK IS INSTU/� Gj -�J I. TANK DESCRIPTION COMPLEm AS VS- SPECIFY IF UNKNOWN A. OWNER'S TANK I.D.a B. MANUFACTURED BY: y, C DATE INSTALLED(MOIDAYNEAR) C D. TANK CAPACITY IN GALLONNS: 101 QOD 11 II.TANKCONTENTS IFA I ISMAs,ED;N-_ErITEMC. �1a REGULAR 3 DIESEL r e %V.ATADNGAS A 1 MOTOR VEHICLE FUEL _ 4 OIL g\ � C• L� UNLEADED PREMIUM H 4 GASAHOL I—' pgT;gNOI ❑ 2 PETROLEUM _ EMPTY T"'�1 PRODUCT ❑ ED D ❑ 5 JET FUEL ❑ 3 CHEMICALPRODUCT I- UNKNOWN ❑ 2 WASTE ❑ 2 LEADED ❑ 99 OTHER (DESCF:"r'- 'N -V D.BELOW) D. IF(A.1)IS NOTMARKED, ENTER NAME OSTORED C.A.S.a: III. TANK CONSTRUCTION MASKONE n ONLY IN BOXES A,B.AND C.AND ALLTHAT APPLIES INBOX D AND --511 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER EJ95 UNKNOWN A. TYPE OF f SYSTEM ❑ 2 SINGLE WALL 4 SECONDARY CONTAINMENT (VAULTED TANK) ❑ 9g OTHER ❑ 1 BARE STEEL ❑ 2 STAINLESS STEEL E:] 3 FIBERGLASS d STEEL CLAD WI FIBERGLASS Rc� DPLASTIC B. TANK 6 POLYVINYL CHLORIDE 7 ALUMINUM B 100% METHANOL COMPATIBLE W�R= MATERIAL ❑ s CONCRETE ❑ E:] ❑ (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED ❑ 2 ALKYD LIN'IN'G ❑ 3 EPDXY LINING ❑ d PHENOLIC LINING C.INTERIOR ❑ 5 GLASS LINING '6 UNLINED El 95 UNKNOWN ❑ 99 OTHER LINING IS LINING M.ATEFIAL COM=A"SEE WITH 100% METHANOL? YES_ NO— D.CORROSION ❑ 1 POLYETHYLENE Wc. ❑ 2 COATING El VINYL WRAP 4 FIBERGLASS REINFORCED PL4S� PROTECTION ❑ 5 CATHODIC PROi:. ,r ❑ 91 NONE ❑95 UNKNOWN ❑ 99 OTHER E.SPILL AND OVERFILL SPILL CONTAINVEK.%STALLED(YEAR OVERFILL PREVENTION EOUIPMENT INSTALLED(YEAR) IV.PIPING INFORMATION CIRCLE A :=ASCV-e GROUND OR U IF UNDERGROUND.BOTH IF APPLICABLE A. SYSTEM TYPEA 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE IN A I�2 DOUBLE WALL A U 3 lINEO TRENCH A U 95 UNKNOWN A U 97 CT•+ER 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 6 CONCRETE A U 7 STEEL W/COATING A U 6 100% METHANOL COW-AT19LE WIFRP PROTECTION A U 9 GALVANIZED S-E1 A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A 99 OTHER r) D. LEAK DETECTION 1 AUTOMATIC LINE LEAK DETECTOR [�] 2 LINE TIGHTNESS TESTING ❑ MONRORING 99 OTHER V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 INVENTCRY RECONCILIATION ❑ 3 VADOZE MONITORING 4 AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING ❑ 6 TANK TESTING 7 INTERSTII.ALVCYTDRING ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION 1.ESTIMATED DATE LAST USED(MO/OAV/YR) 12.ESTIMATED OUANTITY OF 3.WAS TANK FILLED WITH ❑ NO❑ SUBSTANCE REMAINING GALLONS INERT MATERIAL? THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO BEST MY KNOVILEDGE, IS TRUE AND CORRECT APPLICANTS NAME DAT IPAI { IGN T R) Ab/ !_ /Y'J Y LOCAL AGENCY USE ONLY f THE STATE I.D.NUMBER IS COMPOSED OFF THE FOUR NUMBERS BELOW COUNTY Y JURISDICTION A FACILITY X �--�TANK k E I.D.# rn STATm � L PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS FORDDNLR{ FORMS (1291)