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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. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ON SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 8 TEMPORARY TANK CLOSURE ❑ B TANK REMOVED ro DBA OR FACILITY NAME WHERE TANK IS INSTALLED: 3 d �. EZ I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A OWNER'S TANK I.D.• B. MANUFACTURED BY: u/_VL� C. DATE INSTALLED(MO/DAYYYEAR) L D. TANK CAPACITY IN GALLONS: II.TANK CONTENTS IF A-1 IS MARKED,COMPLETE ITEM C. A ❑ 1 MOTOR VEHICLE FUEL 4 OIL B. C. ❑ IS REGULAR UNLEADED ❑ 3 DIESEL ❑ 8 AVIATION GAS 2 PETROLEUM80 EMPTY 1 PRODUCT� ❑ lb PREMIUM UNLEADED E] 4 GASAHOL [:] 7 METHANOL j�� ❑ ❑ ❑ Ic MIDGRADE UNLEADED ❑ 5 JETFUEL ❑ 8 M85 ❑ 3 CHEMICALPRODUCT ❑ 95 UNKNOWN 2 WASTE 1 2 LEADED ❑ 99 OTHER(DESCRIBE IN IfEMO.BELOW) D. IF(A1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED - C.A S. 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 I BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL 5 CONCRETE ❑ 8 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP (pT'-Oy T-k) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER C.INTERIOR ❑ 1 RUBBER LINED F7 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING LINING OR ❑ 5 GLASS LINING XB UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 10D% METHANOL? YES— NOLX D.EXTERIOR ❑ I POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC CORROSION PROTECTION ❑ 5 CATHODIC PROTECTION W91 NONE ❑95 UNKNOWN ❑ 99 OTHER E SPILL AND OVERFILL,BIC. SPILL CONTAINMENT INSTALLED R) VE FRILL PREVENTION EQUIPMENT INSTALLED(YEAR) DROP TUBE YES_ NO IKERPLATE 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 A U 2 PRESSURE A 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION AQ)I SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND Aln1 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 a CONCRETE A U 7 STEEL W/COATING A U 8 ID0% METHANOL COMPATIBLE WIFRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION 1 ME =R ME LEAK 2 NNE TIGNI M 3 CONTINUWS IMB6TIIIAL 4 ELEC9i0NIC LINE 5 AUTOIMTC WLP ❑ OELECfOR ❑ TESTIM ❑ MONi0RM0 ❑ LTAK DETECTOR I� SKII nC 99 OTHER Al V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 RECONCAL ILIATION CILIATIONORY ❑ 3 MAODOZE NIITORING ❑ 4 GAUGING AUTOMATIC TANK ❑ 5 GROUND MONITORING TESTING❑8 TTESTINGTANK ❑ 7 MONITORINGINTERSTITIAL ❑ B SIR ❑ 9 TALY NK GAUGING ❑10 MONTHLYTESTING TANK 95 UNKNOWN ❑99 OTHER VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) 1.ESTIMATED DATE LAST USED O/DAY/YR) 2.ESTIMATED OUANTITV OF 3.WAS TANK FILLED WITH Y ❑ a,- SUBSTANCE REMAINING —.Cc—GALLONS INERT MATERIAL? NO 91 THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE WD CORRECT TANK OWNER'S NAME DATE (PPINTFD S SIGNANREI LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOWPk Q COUNTYM JURISDICTION M FACILITY k - KO STATE I.D.# (, PERMIT NUMBER PERMIT APPROVED BYIDATE PERMIT EXP j5'j4 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 SHOULDBE ACCOMPANIED BYYLA PLOT PI Fl THIS FORM)NITH THE LOCAL AGENCY IMPLEMENTING MTHE""yERGGRRO'UN�DDSTORAGE ...TANK /REGULATIONS FORM B (695) A�C��