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STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B > , •�4n0 COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT L:] 8 TEMPORARY TANK CLOSURE ® 8 TANK REMOVED D DBA OR FACILITY NAME WHERE TANK IS INSTALLED: 14 On-( W4 5fAFUMJ366 ✓'� I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN F.SC A OWNER'S TANK I.D.N fAl-t1f B. MANUFACTURED BY: C. DATE INSTALLED(MO/DAYNFAR) -0 1 / r'- D. TANK CAPACITY IN GALLONS: S W II.TANK CONTENTS IF A-1 IS MARKED.COMPLETE TEM C. A 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C. a REGULAR UNLEADED O 3 DIESEL ❑ 8 AVIATION GAS O 2 PETROLEUM ❑ 80 EMPTY ❑ 1 PRODUCT IE PREMNM UNAFIDED ❑ 4 GASAHOL ❑ 7 METHANOL ❑ 1t MIDGRADE UNLEADED 5 JET FUEL ❑ 8 M85 ED CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE El LEADED 99 OTHER(DESCRIBE IN ITEM D.BELOYR D. IF(A1)IS NOT MARKED, ENTER NAME O SUBSTANCE STORED C.A 10: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A B,AND C,AND ALLAPPUES IN BOX D AND E A. TYPE OF ❑ I DOUBLE WALL ❑ 3 SINGLE WALL WITH IOR LINER a S INTERNAL BLADDER SYSTEM ❑ 95 UNKNOWN SYSTEM �® 2 SINGLE WALL ❑ 4 SINGLE WALL IN AULT ❑ 99 OTHER B. TANK .In 1 BARE STEEL ❑ 2 STAINLESS EL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 8 POLYVI CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP (Pdmary Twk) ❑ 9 BRONZE ❑ 10 GA ANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER C.INTERIOR ❑ 1 RUBBER LINED 42/ LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING LINING OR ❑ 5 GLASS LINING UNLINEDB5 UNIOJOWN ❑ % OTHER COATING IS LINING MATERIAL COMPATIBL100% METHANOL? YES— NO— D.EXTERIOR ❑ 1 POLYETHYLENE WRAP 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC CORROSION PROTECTION ❑ 5 CATHODIC PROTECTION 91 CNE ❑95 UNKNOWN ❑ 99 OTHER E.SPILL AND OVERFILL,NLO. SPILL CONTAINMENT 14STALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) DROP TUBE YES I NO_ STRIKER PLATE YES_ NO_ DISPENSER CONTAINMENT YES_ NO IV,PIPING INFORMATION CIRCLE A FABOVE 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 WALLA U 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 09 OTHER C. MATERIAL AND U 1 BARE STEELA 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 Wt COATING A U B 10D% 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 11 1 YEaMNGt UNE LEJK 0 2 LHE TBMIE33 O 3 f/JIIIRIU9U3 N1EASiRML O 4 EIFCTROMC UNE O 5 AUI9MTC RAP O 99 OTHER OEIECTOR TE311N9 M3R1D9Na UmoElEcroa slumonx V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 RECONCILIATION CILATIONORV ❑ 3 VADOZE M ORING ❑ 4 GAUG AUTOMATIC TANK ❑8 GROUND WATER ❑ e ANNUALTES-INGTANK ❑ 7 MONITORING INTERSTITIAL ❑ 8 SIR ❑ 9 TANK LA MANGAL ❑ 10 TESTINGLY TANK ❑ 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION(PERMANENT OLDBUR IN-PLACE) 1. TED DA L�f USED(MOIDAY/YR) 2.ESTI TED QUANTITY OF 3.WAS TANK FILLED WITH YES ❑ NO� 011 I ICT b SUB ACE REMAININGGALLONS IN MATERIAL? // THIS FORM HAS BEEN COMPLETED UNDER PEN TY OF PERJURY, ND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT TANK OWNERS RE I LK Q �r DATE 12-2-x-1 (PPPRED 1 SIONATUNB) LOCAL AGENCY USE ONLY THE STATE I.D.N BER IS COMPOSED OF THE FOUR NUMBERS BELOW 3 COJURISDICTION N FACILITY N STATE D# � � p PERMIT NUMBER PERMIT APPROVED BYIDATE 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 PI�N. RLE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS FORMS (8.95) _ _ Q.��3� 9 nT