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STATE OF CALIFORNIA • • + STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B ge ° I COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION7 PERMANENTLY CLOSP- ONE ITEM ❑ 2 INTERIM PERMIT sli 4 AMENDED PERMIT E] 6 TEMPORARY TANK CLOSURE 8 TANK REMOVEDf-6 DBA OR FACILITY NAME WHERE TANK IS INSTALLED: m I(??.. mkwul VbkmtT • Gh I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN l A. OWNERS TANK I.D.i B. MANUFACTURED BY: C. DATE INSTALLED(MO/DAYNEM) V„)n D. TANK CAPACITY IN GALLONS: OO II.TANK CONTENTS IF A-1 IS MARKED,COMPLETE ITEM C. p <1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C. T-� le REGULAR UMEADED 3 DIESEL ❑ 6 AVIATION GAS ❑ 2 PETROLEUM ❑ 80 EMPTY 1 PRODUCT l l:PREMUM UNLEADED 4 GASMOL ❑ 7 METHANOL [� 1c MDGRADE UIIEADED 5 JET FUEL ❑ 8 M85 ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED 99 OTHERMESCRISENITFMD.BBDL'0 D. IF(A-1)IS NOT MARKED, ENTER NAME OFSUBSTANCE STORED C.&SN: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.B,AND C.AND ALL THAT APPLIES IN BOX D AND A. TYPE OF ❑ 1 DOUBLE WALL ❑ 3 61NGLE WALL WITH EXTERIOR LINER ❑ 5 INTERNAL BLADDER SYSTEM ❑ 95 UNKNOWN SYSTEM 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 ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 10D% METHANOL COMPATIBLE W/FRP (PHXKNY T-k) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER C.INTERIOR ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ,,��❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING LINING OR ❑ 5 GLASS LINING ❑ 6 UNLINED 95 UNKNOWN ❑ 99 OTHER COATINGGIS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO— D.EXTERIOR ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC CORROSION PROTECTION ❑ 5 CATHODIC PROTECTION 91 NONE ❑95 UNKNOWN ❑ 99 OTHER E.SPILL AND OVERFILL,etc. SPILL CONTAINMENT INS? D(YEAR) OVERFILL EVETYTION EQUIPMENT INSTALLED(YEAR) DROP TUBE YES NO_ STRIKER PLATE YES NO_ DISPENSER CONTAINMENT YES o NO IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND,BOTH IF APPLICABLE er- A. SYSTEM TYPE A U 1 SUCTION A 2 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL A 0 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND A U 1 BARE STEEL Will 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A U 4 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A 6 CONCRETE A U 7 STEEL W1 COATING A U 8 100% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION ❑i KEf,M,1NG1L UK LEAK ❑2 ❑3 wXriAlols N18+snruL 4 13E018014C WE ❑s AVTOIMTK RAP ❑ 99 OTHER oETEcroR 1ESIKM IlaNranq 6AIX IATECfdi BKIIODWN V.TANK LEAK DETECTION ❑ i VISUAL CHECK ❑ 2ANUUAL INVENTORY ❑LIATION 3 VADOZMONITORINGN5Q4 AUTOMAGAUGINTIC TANK ❑ 5 GROUNDINGWATER ❑ 6 ANNUAGTANK ❑ 7 CONTINUMONITORIWNGS INTERSTITIAL ❑ 8 SIR REC ❑ 9 WE K LY MANUTESTING AL ❑10 MONTHY TANK ❑ 95 UNKNOWN E] 99 OTHER VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) �/ 1.ESTIMATED TE USE ( AYNA) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES ❑ NO SUBSTANCE REMAINING GALLONS INERTMATERIAL? THIS F RM H S BEEN tompLETED UNDER=jk Oe PERJUR AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT TANK OWNER'S NAME DATE (PRNfm4SK31UTURE) /. //- ]� LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW / COUNTY N JURISDICTION N FACILITY N TANK N STATE I.D.# PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLM"'ON-FORM A,UNLESS A CURRENT FORMA HAS BEEN FILED. FORM C MUST BE COMPLETED FOR INSTALLATIONS. THIS FORM SHOULD BE ACCOMPANIED BY A PLOT III (dILEETTHIS FORM WITH THE LLOCALL AGENCY IMPLEMENTING THE' `RGROUND STORAGE TANK RgGGUULLATIONS FORM 8 (695) - I V J X-' c• I