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`. .use '�Sawces STATE OF CALIFORNIA P .V STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B s� COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED ON SITE ONE ITEM ❑ 2 INTERIM PERMIT O 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE 6 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: ETI AA( O '['(LUCK_ P L,4Z A�- I. TANK DESCRIPTION COMPLETE,ALL ITEMS— SPECIFY IF UNKNOWN A. OWNERS TANK 1.D.M 3 B. MANUFACTURED BY: C. DATE INSTALLED(MOIDAYNEAR) V IV"tvi I D. TANK CAPACITY IN GALLONS: Z II.TANK CONTENTS IF A-1 IS MARKED,COMPLETE ITEM C. p 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C ❑ 1a REGULAR UNLEADED �3 DIESEL ❑ 6 AVIATIONGAS ❑ lb PREMIUM UNLEADED 4 GASAHOL ❑ 7 METHANOL ❑ 2 PETROLEUM ❑ BO EMPTY �1 PRODUCT E] 1c MlOGRADE UNLEADED ❑ 5 JET FUEL ❑ 8 M65 ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEACHED 99 OTHER(DESCRIBE 110.BELOV1) D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S.N 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 ❑ 1 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 Wl FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 6 100% METHANOL COMPATIBLE WJFRP ('Primary Tank) ❑ 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 UNLNFD ❑ 95 NKNOWN ❑ 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES— NO_ D.EXTERIOR ❑ 1 POLYETHYLENE WRAP 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC CORROSION PROTECTION E] 5 CATHODIC PROTECTION ❑ 99 NONE O5 UNKNOWN ❑ 99 OTHER SPILL CONTAINMENT IN}TALLED(YEAR) OVERFILL P NO EQUIPMENT INSTALLED(YEAR) / E.SPILL AND OVERFILL,PlC. DROP TUBE YES V NO STRIKER PLATE YES NO DISPENSER CONTAINMENT YES NOy IV, PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND,BOTH IF APPLICABLE 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/ 1 SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND A(!) 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 STEELWICOATING A U 8 100% METHANOL COVPATIBLEWIFRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION FVIII.EC.ICAL UNE LEAK2 LINE 71GKTNESS 3 CONTINUOUS INTERSTITIAL 4 ELECTRONIC LINE 5 AUTOMATIC PUMP DETECTOR ❑ TESTING MONITORING [7LEAK DETECTOR SHUMOVIN 99 OTHER V.TANK LEAK DETECTION ❑' I VISUAL CHECK ❑ 2 MANUAL RECONCILIAT10NORY ❑ 3 MONITORING - 4 AUTOMATGAUGING IC TANK ❑ 5 MO©TORINGUND TER ❑ 6 ANNUALMONITORING ❑ 7 MONITOR OUG INTERSTITIAL ❑ 8 SIFt ❑ 9 EEK LY MANUAL ❑ 10 MO TESTINLY TANK ❑ 95 UNKNOWN Q 99 OTHER GIG VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) 1.ESTIMATED DATE LAST USED(MOICAYIYR)A)/,A- 1 � 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH M SUBSTANCE REMAINING GALLONS INERT MATERIAL? THIS FORM HAS BEEN COMPLETED UNDER PEATY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT TANK OWNER'S NAME DATE (PRINTED h SIGNATURE) �(� L r,C I ) LOCAL AGENCY USE ONLY THE STATE I. MBER IS COMPOSED OF THE FOUR NUMBERS BELOW k � V [ COUNTY# JURISDICTION# FACILITY N TANK# STATE I.D:# L] I = 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 PLOT PLAN. FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS FORM B (6-95)