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STATE OF CALIFORNIA i, STATE WATER RESOURCES CONTROL BOARD ;�. UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B °�°e ~ '° i COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT F7 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION 1:J7 PERMANENTLY CLOSED ON SITE ONE REM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: a !p. 04.Al 57— GOb/ I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A OWNERS TANK 1.[L# v &- B. MANUFACTURED BY: C. DATE INSTALLED(MO/DAY/YEAR) All. C D. TANK CAPACITY IN GALLONS: .7 II.TANK CONTENTS IF A-1 IS MARKED,COMPLETE ITEM C. A CNI 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C. la REGULM UNLEADED &j 3 DIESEL E] 8 AVIATION GAS F72 PETROLEUM E:] 80 EMPTY 1 PRODUCT ❑ 1b PREMIUM UNLEADED L_]-4 GASAHOL ❑ 7 METHANOL ❑ 8 M85 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE E::] 2 LLE D DE UNLEADED 99 OTKERIDESCRJETFUEL ❑IBEINREMD.BELOWI D. IF(A.1)IS NOT MARKED. ENTER NAME OF SUBSTAGE 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 N 95 UNKNOWN SYSTEM ❑ 2 SINGLE WALL ❑ 4 SINGLE WALL IN A VAULT ❑ 99 OTHER B. TANK ❑ 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM E::] B 100% METHANOL COMPATIBLE W/FRP ��1 (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL IAC 95 UNKNOWN ❑ 99 OTHER C.INTERIOR ❑ I RUBBER LINED ❑ 2 ALKYD LINING /—❑ 3 EPDXY LINING E:] 4 PHENOLIC LINING LINING OR F-15 GLASS LINING ❑ 6 UNLINED y�1 95 UNKNOWN ❑ 99 OTHER COATING IS UNING MATERIAL COMPATIBLE WITH 100% METHANOL? IN IS NO D.EXTERIOR ❑ T POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC CORROSION PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE IK 95 UNKNOWN ❑ 99 OTHER E.SPILL AND OVERFILL,Lit. 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 U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL A U 2- DOUBLE WALL A U 3 LINED TRENCH Aa?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 6 100% METHANOL COMPATIBLE VY/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION 80995 UNKNOWN A U 99 OTHER D. LEAK DETECTION3 1 "°s°Iwar'"L"xE LF"Ic u'E^°"r�ss oanauous IxrsasTmu B.EcmoNc un6 Avrawnc MAP ❑ pEIECIDR ❑2 TU Na ❑ M Ta6Ma ❑a tFAK 9ETECT011 ❑5 SMlial)NN ❑ 99 OTHER V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 RECO CIUATIONNUAL ORV ❑ 3 MONIITORING VAOZE ❑ 4 GAUGINGAUTOMAT TANK ❑5 ONTORING�R ❑ 8 TESTING ❑ 7 CONTINUOUS INTERSTITIAL ❑ B SIR ❑ 9 WEEKLY MANUAL E] NT 10 M HHLY TANK 95 UNKNOWN E::] 99 OTHER TANVI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) 1.ESTIMATED27, TE U D(MO/DAY/YR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES ❑ NO❑ SUBSTANCE REMAINING D 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 (PRNTEDa SIONATURET LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# TANK# STATE I.D:# m E:= PERMIT NUMBER PERMIT APPROVED BV/DATE PERMIT EXPIRATION DATE THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORMA HAS BEEN FILED. FORM C MUST BE COMPLETED FOR INSTALLATIONS.THIS FORM SHOULD BE ACCOMPANIED BY A PLOT PL -ILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE I'•-^ RGROUND STORAGE TANK REGULATIONS FORMS (6-95) % / -..- G 11000