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STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD " UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. 9 MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT CHANGE OF INFORMATION .508 7 PERMANENTLY CLOSED ONSITE ONE ITEM F-12 INTERIM PERMIT F-14 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE 8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: IYE? 4 I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A OWNERS TANK I.D.♦ 7 S. MANUFACTURED BY: C. DATE INSTALLED(MOIDAY/YEAR) D. TANK CAPACITY IN GALLONS: 1)00 H.TANK CONTENTS IF A-1 IS MARKED,COMPLETE ITEM C. A >4.1 MOTOR VEHICLE FUEL ❑ 4 OIL B.�T C. 1. REGULAR UNLEADED ❑ 3 DIESEL ❑ 6 AVIATIONGAS ❑ 2 PETROLEUM ❑ 80 EMPTY 17(,I 1 PRODUCT ❑ ib PREMIUM UNLEADED ❑ 4 GASAHOL O 7 METHANOL ❑ 3 CHEMICALPRODUCT ❑ 95 UNKNOWN T❑' 2 WASTE ❑ 2c MIDGRALEADED 99 UNLEADED a 99J TM�EDESCR❑ a MRS IBE IN ITEM D.BELOM D. IF(A.1)IS NOT MARKED, ENTER NAME OFSUBSTANCE STORED C.A.S. 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 INTERNAL BLADDER SYSTEM ❑ 95 UNKNOWN SYSTEM 2 SINGLE WALL ❑ 4 SINGLE WALL IN A VAULT ❑ 99 OTHER B. TANK 1 BARE STEEL O 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE O 8 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ B 100% METHANOL COMPATIBLE W/FRP (Primary Tmk) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER C.INTERIOR ❑ 1 RUBBER LINED O 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING LINING OR ❑ 5 GLASS LINING 6 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 10D% METHANOL? YES_ NO3C D.EXTERIOR ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC CORROSION PROTECTION ❑ 5 CATHODIC PROTECTION X 91 NONE ❑95 UNKNOWN ❑ 99 OTHER E SPILL AND OVERFILL,BIC. SPILLCONTAINMENT INSTALLE (Y R) OVERFILL PREVE ON OUIPMENT INSTALLED(YEAR) DROP TUBE YES_ NO I R PLATE YES_ NO DISPENSER CONTAINMENT TEW_ NO IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLEPIPING A U 99 OTHER B. CONSTRUCTION A V SINGLE WALL A U 2 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)A U 4 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL W/COATING A U 8 10D% METHANOL COMPATIBLE WI PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION1 AYCWHfAI ME UIM 2 ME TIGR W 3 Ca UWS INIAIXaG IERST 4 M Ura 5 A9r0MADC N" ❑ DEIECT011 ❑ TESTN9 MOMTDIIING ❑ LEAK DEITOTOR ❑ SIA1100WX 99 OTHER V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 MANUAL ECONCILATIONORY ❑ 3 VADOZE ❑ 4 AUTOMAGAUGINTIC TANK E:]5 MONITORING DWATER E::] 6 ANNUAGTANK ❑ 7 MONITORING INTERSTITIAL ❑ 8 SIR ❑ 9 WEEKLY LY MANUAL ❑10 MONTITHHLY TANK 95 UNKNOWN ❑99 OTHER VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PUCE) 1.ESTMA D GATE LAST U D MO/DAY/YR) 2.ESTIMATED OUANTTTY OF 3.WAS TANK FILLED WITH YES ❑ 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 OWNERS NAME DATE (PRW aSIGNATURE) LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OFTHE FOUR NUMBERS BELOW COUNTY k JURISDICTION A FACILITY f TANK# OO STATE I.D.# Zfll 5-0 I& I3 7 X 1:311713 PERMIT NUMBER PERMIT APPROVED BYIDATE PERMIT EXPIRATION 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 PLAN. FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS FORM 8 (6-95) JD-3 - f& 1 A/Q