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\i STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM B •X41,pl COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY 1 NEW PERMIT O 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOW.DQNSITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT O 6 TEMPORARY TANK CLOSURE O 8 TANK REMOVED 1� DBA OR FACILITY NAME WHERE TANK IS INSTALLED: Sc,/et_K -e .-v .>~c- WV` l( I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A OWNER'S TANK I.D.• B. MANUFACTURED BY: C. DATE INSTALLED(MO/DAWYEAR) 1 c �,1 D. TANK CAPACITY IN GALLONS: o, II.TANK CONTENTS IF A-1 IS MARKED,COMPLETE ITEM C. A. 1 ET�MOTOR VEHICLE FUEL O 4 OIL B. C, le REGULAR UNLEADED 3 DIESEL 8 AVIATION GAS ❑ 2 PETROLEUM ❑ 80 EMPTYRODUCT ❑ ib PREMIUM UNLEADED 4 GASAHOL ❑ 7 METHANOL ❑ 10 MIDGRADE UNLEADED E:] 5 JET FUEL ❑ 8 M85 ❑ 3 CHEMICAL PRODUCT ❑ BS UNKNOWN ❑ 2 WASTE ❑ 2 LEADED ❑ 99 OHER(OESCRIBE N ITENID.BELOW) D. IF(AI)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A S.•: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A 8,AND C,AND ALL THAT APPLIES IN BOX D AND E A. TYPE OF ❑ BLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER 5 INTERNAL BLADDER SYSTEM ❑ 95 UNKNOWN SYSTEM 1�- 2 SINGLE WALL ❑ 4 SINGLE WALL IN A VAULT ❑ 99 OTHER B. TANK -YJ 1 BARE STEEL ❑ 2 STAINLESS STEEL a 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP (PHMWY Tok) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER C.INTERIOR ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOUC LINING LINING OR ❑ 5 GLASS LINING B UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH IDD% METHANOL? YES_ NO— D.EXTERIOR a 1 POLYETHYLENE WRAP O 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC CORROSION PROTECTION ❑ 5 CATHODIC PROTECTION 91 NONE ❑95 UNKNOWN ❑ 99 OTHER E.SPILL AND OVERFILL,8lC. SPILL CONTAINMENT INSTALLED(YEA OVERFILL PREVENTION EOUWAENT INSTALLED(YEAR) j 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 APPUCABLE A. SYSTEM TYPE ArQ 11 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION A&A 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 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 8 100% METHANOL COMPATIBLE W/FRP PROTECTION A©9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION 1 IEcx.NCAI uHE LEAIc ❑2 UK T K!Iss �3 ca9RN.lDU9 N1E15i1ML ❑4 ElAMW UK ❑5 AMl =wLa ❑ o— OEiECfIXI TESTNO MMTMIW [EAI(OEIECTOR NNf00Ml 99 OTHER V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 RECONCILIATIONORV ❑ 3 MONITORING ORING ❑ GAUGING AUTOMATIC TANK ❑8 MONITORINGTER ❑8 TESTING ❑ 7 MONITORING INTERSTITIAL ❑ 8 SIR ❑ 9 WEEKLY MANUAL ❑10 MONTHLY TANK � UNKNOWN ❑ 99 OTHER NG VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) 1.ESTIMATED DATE LAST USED(MO/DAY/YR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES O NO❑ SUBSTANCE REMAINING GALLONS INERTMATERIAL? THIS FORM HAS BEEN COMPLETED UNDER PENALTY OFPERJqRY,AND TO HE BEST OF MY OWLEDGE,IS TRUE AND CORRECT TANK OWNER'S NAME \O AL DATE —� (PRINTm89GNATURET / �- LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED dFTHc rh1lo NUMBERS BELOW COUNTY N JURISDICTION M FACILITY N (a TANK R / STATE LD:# 6 t 7A /�� 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 A PLO' N. FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING T' 'NDERGROUND STORAGE TANK REGULATIONS FORMS (6.95) '•' —