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STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD •` '"+ c++ 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 tg_§,,,TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A OWNERS TANK I.D.If 1 .� \ B. MANUFACTURED BY: ee_ , ` .G 7m C. DATE INSTALLED(MO/DAVKEAR) D. TANK CAPACITY IN GALLONS- II. II.TANK CONTENTS IF A-1 IS MARKED,COMPLETE ITEM C. �/lJ A 711 MOTOR VEHICLE FUEL ❑ 4 OIL B. p_ to REGLIAR UNLEADED O 3 DIESEL O 6 AVIATION GAS ❑ E PETROLEUM — EMPTY PRODUCT [:] 1b PREMMM UNLEADED O 4 GASAHOL ❑ 7 METHANOL 3 CHEMICALPRODUCT 95 UNKCWN ❑ 2 WASTE ❑ IC MIDGRADE UNLEADED 5 JET FUEL ❑ 8 M85 ❑ 2 LEADED 89 OTHFA(DESCRIBE N REM D.BELOWI D. IF(A1)IS NOT MARKED. ENTER NAME OF SUBSTANCE STORED A^•.NL�t..)��. __ 1'�A �_ 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 1 DOUBLE WALL O 3 SINGLE WALL WITH EXTERIOR LINER a 5 INTERNAL KAMER SYSTEM Dgq5 UNKNOWN SYSTEM 2 SINGLE WALL ❑ 4 SINGLE WALL IN A VAULT O 99 OTHER B. TANK ❑ I BARE STEEL O 2 STAINLESS STEEL 03 FIBERGLASS 4 STEEL CUD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE O 8 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ B 100% METHANOL COMPATIBLE W/FRP (Primary Tank) ❑ 9 BRONZE O 10 GALVANIZED STEEL O 95 UNKNOWN O 99 OTHER C.INTERIOR ❑ I RUBBER LINED ❑ 2 ALKYD UNING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING LINING OR ❑ 5 GLASS LINING ❑ 8 UNLINED FZ2'95 UNKNOWN E:] 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 10D% METHANOL? YES_ NO_ D.EXTERIOR ❑ 1 POLVETNYLENE WRAP -2 COATING CORROSION ❑ 3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 CNE O 95 UNKNOWN Q 99 OTHER E SPILL AND OVERFILL,BIO, SPILL CONTAINM 1 STALLED(YEAR) OVER REVENTION ECUIPMENT INSTALLED(YEAR) DROP TUBE YES C_ 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 U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION A l�l 1 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 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 8 100% 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 1 IrLcxuacu LaK uAK 2 uK minrEss a CCxtrAlolB anERalmM 4 Elccmaae M 5 AyrOwTm MW ❑ 9DEmoa tEmw9 ❑ MCMrCRNO ❑ am oE1[cr9R ❑ 9Art9DmI ❑ 99 OTHER V.TANK LEAK DETECTION TANK ❑ 1 VISUAL CHECK ❑ 2 REECCOUAL CIUAT10NORY ❑ 3 MAONNIITORING Y�"ZE 4 GAUGING TANK ❑5 GROUNDWATER ❑8 TESTING 7 MONIS INTERSTITIAL ❑ 8 SIR ❑ B WEEKLY MANUAL ❑10 MONTHLY TANK ❑ 95 UNKNOWN ❑99 OTHER TANK GAUGING TESTING VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) 1.EsTiM DATE USED(MO/DAV/YR) 2.ESTIMATED OUANTITY OF 3.WAS TANK RI I ED WITH YES O C� SUBSTAGE REMAINING _GALLONS INERT MATERIAL? THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT TAANI 16m6NEllINAME LLG / L"' a DATE Cranbevo�CffSSoola�c5, Am sF Deyftwr LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY N JURISDICTION M FACILITY RTANK M STATE I.D.# m FA W, Ls I ol I O 0151 a ?11 PERMIT NUMBER PERMIT APPROVED BYADATE PERMITE%PIRATION DATE 4: THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPUCATION-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. FORM C MUST BE COMPLETED FOR UISTALLATIONS.THIS FORM SHOULD BE ACCOMPANIED BY A PLOT PI ILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE' TNGROUND STORAGE TANKR LA FORMS (6.95) \r/ �..+ t91ID 91