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STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION-FORM B s g COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ® 1 NEW PERMIT ;;� ❑ ONE ITEM ❑ 3 RENEWAL PERMI7 5 CHANGE OF INFORMATION ❑ 2 INTERIM PERMIT4 AMENDED PERMIT ? PERMANENTLY CLOSED ONSI6 TEMPORARY TANK CLOSUREDBA OR FACILITY NAME WNERE TANK IS IN17 R'. Elm St . parking lot ❑ SI REMOVED y I. TANK DESCRIPTION COMPLETE ALL ITEMS_ SPECIFY IF UNKNOWN A OWNER'S TANK I.D. none B. MANUFACTURED BY: C. DATE INSTALLED(MOA11Y/YEgR) unknown UnknOWn D. TANK CAPACITY IN GALLONS: 3 t0 500 II.TANK CONTENTS IFA-1 15 MARKED,COMPLETE ITEM C. gallons A r 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C. 1a flEGULAq UNLEADED 3 DIESEL ❑ 8 AVIATION OAS ❑ 2 PETROLEUM ❑ 80 EMPTY ® 1 PRODUCT ❑ 1b PgEMIUM UNLEADED 4 GASAHOL Q 7 METHANOL ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 1e MIDGRADE U11LE1DED F] 5 JET FUEL ❑ B MBS ❑ 2 LEADED 99 OTHER(DESCRIBE N REM D.BELOW) D. IF(AA)IS NOT MARKED. ENTER NAME OF SUBSTANCE STORED C.AS.#: ill. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A B.AND C.AND ALL THAT APPLIES IN BOXD AND 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 I BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W1 FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 8 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ B 100% METHANOL COMPATIBLE W/FRP (POMMY TMk) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER C.INTERIOR ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC UNING LINING OR ❑ 5 GLASS LINING ® 8 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER COATING IS LINING MATERIAL COMPAT18LE WITH 100% METHANOL? YES— NO— D.EXTERIOR ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC CORROSION PROTECTION PROTECTION ❑ 5 CATHODIC PROTECTION n 91 NONE D8 UNKNOWN E:] 99 OTHER E SPILL AND OVERFILL,Bh. SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT 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 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION A l SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND A O I 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 B CONCRETE A U 7 STEEL W/COATING A U B 100%METHANOL COMPATIBLE NFRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 1 YEDMNI'.LL LME M9Mraml9 TOR 9art0owx OTHER O2 NE NM 3 4 TEIXUN 99 OTH0 __Non, D. LEAK DETECTION 0--1 ffi 7S V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 RECONCILIATION INVENTORY ❑ 3 MONITORING ❑ 4 GAUGING AUTOMATIC TANK ❑5 MONTORINGOUND TER ❑ 9 TESTING ANNUALTMIK ❑ 7 MO TIN US INTERSTITIAL ❑ 8 SIR ❑ 9 WE�TANK AUMANUAL ❑10 MONTHGING LY TANK n 95 UNKNOWN ❑99 OTHER VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PUCE) �r 1.ESTIMATED DATE LAST USED(MO/DAYNR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES O NO❑ SUBSTANCE REMAINING GALLONS INERT MATERIAL? THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT TANK OWNER'S NAME DATE (PPINiFD 4 SI9NANPE) �� . I'4 x,11 , 3/23/()l LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW r 6 /a 7 9 COUNTY M JURISDICTION# FACILITY M TANK# STATE I.D.# m = FT13=1. 0 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. FORM C MUST BE COMPLETED FOR INSTALLATIONS.THIS FORM SHOULD BE ACCOMPANIED By PLOT PUN. FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMF"NG THE UNDERGROUND STORAGE TANK REGULATIONS FORMS (&95) �y