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py�r�g STATE OF CALIFORNIA .' STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B 1 i • o COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY F-1 I NEW PERMIT r_1 3 RENEWAL PERMIT n 5 CHANGE OF INFORMATION 77 7 PERMANENTLY CLOSED ON SITE ONE ITEM 7] 2 INTERIM PERMIT Ll 4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE '� 8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: I mGD I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A. OWNER'S TANK I.D,a -7 B.. MANUFACTURED BY, VP✓KAjoulN C. DATE INSTALLED(MOIDAYNEAR) V f,) fl 0 I,A/1j D. TANK CAPACITY IN GALLONS: 10 / p©0 II.TANK CONTENTS IF A-1 IS MARKED,COMPLETE ITEM C. A �1 MOTOR VEHICLE FUEL a 4 OIL B. C. 1a REGULAR UNLEADED 3 DIESEL E 6 AVIATION GAS 2 PETROLEUM El 80 EMPTY Esr 1 PRODUCT1D PREMIUM UNLEADED a 4 GASAHOL 7 METHANOL 1c MIDGRADE UNLEADED 5 JET FUEL 8 M85 3 CHEMICAL PRODUCT 95 UNKNOWN 2 WASTE 1--] 2 LEADED Ej 99 OTHER(DESCRIBE IN ITEM BELOW) D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S.a III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A,B,AND C,AND ALL THATAPPLIES IN BOR D AND E A. TYPE OF D 1 DOUBLE WALL O 3 SINGLE WALL WITH EXTERIOR LINER 5 INTERNAL BLADDER SYSTEM O 95 UNKNOWN SYSTEM bl 2 SINGLE WALL O 4 SINGLE WALT. IN A VAULT 99 OTHER B. TANK 1 BARE STEEL F-] 2 STAINLESS STEEL 3 PMERGLASS 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL F-1 5 CONCRETE El 6 POLYVINYL CHLORIDE 7 ALUMINUM 8 100% METHANOL COMPATIBLE WIFRP (Primary Tank) El 9 BRONZE O 10 GALVANIZED STEEL ID 45 UNKNOWN a 99 OTHER C.INTERIOR F7 1 RUBBER LINED F7 2 ALKYD LINING 3 EPDXY LINING [::] 4 PHENOLIC LINING LINING OR F__] 5 GLASS LINING �Rr6 UNLINED 95UNKNOWN1-7199 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES % NO D.EXTERIOR F-1 1 POLYETHYLENE WRAP O 2 COATING F-1 3 VINYL WRAP 4 F18ERGLASS REINFORCED PLASTIC CORROSION PROTECTION 5 CATHODIC PROTECTION 91 NONE K95 UNKNOWN 99 OTHER E.SPILL AND OVERFILL,BtC. SPILL CONTAINMENT IN ALLED(YEAR) OVERFILL P VENTION 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 i SUCTION A U - PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER S. CONSTRUCTION A(g) 1 SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND Aa 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 COMPATOBLE WIFRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN U 99 OTHER _ MECHANICAL UNE LEAK 2 LINE AL 4 ELECTRONIC UNE 5 AUTOMATIC PUMP I� 99 {}TREK D. LEAK DETECTION DETECTOR TESTI3 CONTINUOUS INTERSTITIAL a MONITORING LEAK DETECTOR SHUTDOWN L I V.TANK LEAK DETECTION 1 VISUAL CHECK E 2 MANUAL RECONCILIATION MONITORING 3 MOI ORING 4 GAUGINGTIC TANK 5 GROUND MON TORINGTER 6 TESTINGTANK 7 CON INUONUGS INTERSTITIAL [:] 8 SIR 9 WEEK LY MAN NUAL 10 MONTTESHLY TANK 95 UNKNOWN 99 OTHER NG VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) 1.ESTIMATED DATE LAST USED(MOIDAYJYR),/4� 2.ESTIMATED QUANTITY OF3.WAS TANK FILLED WITH `" � SUBSTANCE REMAINING A-GALLONS INERT MATERIAL? THIS FORM HAS BEEN COMPLETED UNDER AL 7-YJK PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT TANK OWNER'S NAME DATE 1PRINTED 6 SIGNATURE) )KIF L� f- �7 LOCAL AGENCY USE ONLY THE STA . .N B COMPOSED OF THE FOUR NUMBERS BELOW COUNTY it JURISDICTION# FACILITY k TANK# STATE 1.D.# _7717 PERMIT NUMBER PERMIT APPROVED BYIDATE 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 PLOT PLAN. FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS 'OHM B (6-95)