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STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD py' o, UNDERGROUND STORAGE TANK PERMIT APPLICATION -FORM B �®' I 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 ❑ ❑ t# 4 AMENDED PERMIT 8 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED I v DBA OR FACILITY NAME WHERE TANK IS INSTALLED: 2 t �� 40 I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A OWNER'S TANK I.D.t B. MANUFACTURED BY: C. DATE INSTALLED(MO/DAYNEAR) D. TANK CAPACITY IN GALLONS: p II.TANK CONTENTS IFA-11S MARKED,COMPLETE ITEM C. A 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C, 1e REGULAR UNLEADED ❑ 3 DIESEL ❑ 8 AVIATION GAS ❑ 2 PETROLEUM ❑ 80 EMPTY I PRODUCT ❑ 10 PREMIUM UNLEADED ❑ 4 GASAHOL ❑ 7 METHANOL ❑ ❑ ❑ 2 LEIc ADED EDE UNLEADED O 99 J TMER PESCR❑ISE IN REM D.BELOW) 3 CHEMICAL PRODUCT BS UNKNOWN 2 WASTE o D. IF(AI)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A S.f: 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 ❑ B 100% METHANOL COMPATIBLE W/FRP (Primary T#Dk) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL Nj 95 UNKNOWN ❑ 99 OTHER C.INTERIOR ❑ I RUBBER UNED ❑ 2 ALKYO LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING LINING OR ❑ 5 GLASS LINING ❑ 8 UNLINED rn( 95 UNKNOWN ❑ 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO— D.EXTERIOR ❑ I POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC CORROSION PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE A95 UNKNOWN ❑ 99 OTHER E.SPILL AND OVERFILL,etc. 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 Z DOUBLE WALL A U 3 LINED TRENCH A 5 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 8 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(%�A UNKNOWN A U 99 OTHER D. LEAK DETECTION1 cx U%UE 2 DME MWNEW 3 cwr WS IM MR 4 ED:cmadc MIA: RMEs AuroMAnc NW E]❑ Crm ❑ M nNG ❑ IAWtMw ❑ Uw CETEcm ❑ $HU1cOWN 99 OTHER V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 MANUAL ECONCILIATIONORY ❑ 3 VAEMONITORING ❑ 4 GAUGINGAUTOMATIC TANK ❑ 5 GROUND WAMON TORINGTER ❑ TANK 8 TESTING ❑ 7NITORING INTERSTITIAL ❑ 8 SIR ❑ 9 TAENK GAUGING ❑IO MONTHLY TANK 5 UNKNOWN ❑99 OTHER VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PUCE) 1.ESTIMATED DATE LAST%( R) 2.ESTIMATED OUANTITY OF 3.WAS TANK FILLED WITH YES ❑ 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 (PRtRm A SIGNATURE) LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY# TANK# STATE I.D.# ff§ = 1610 IspIc'1417 K101,7101 PERMIT NUMBER ERMIT APPROVED SY/DATE PERMIT EXPIRATION DATE Ag :VIE 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 A PLOT P' FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THF -'1ERGROUND STORAGE TANK REGULATIONS FORM B (695) --