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STATE OF CAUFORNIA STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION-FORM B �tl COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOS ONE REM ❑ 2 INTERIM PERMIT ❑ A AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED O' DBA OR FACILITY NAME WHERE TANK IS INSTALLED: /OGz- ' FE / I. TANK DESCRIPTION COMPLETE ALL ITEMS— SPECIFY IF UNKNOWN A OWNERS TANK 1.0.0 It .sr B. MANUFACTURED 871GI ( .FA-4 / O DATE INSTALLED(MC/DAWYEAR) 1 D. TANK CAPACITY IN GALLONS: gj D OC7 II,TANK CONTENTS IFA-1 IS MARKED,COMPLETE ITEM C. A 1 MOTOR VEHICLE FUEL ❑ s OIL B. C. 3 REGUWi UNIFMEo 3 DIESEL ❑ 6 AVIATION GAS 10 PREMBIM UNLEADED 6 GASAHO. ❑ T METHANOL 2 PETROLEUM ❑ 80 EMPTY �I PRODUCT I tc MIDGRADE UNlEAOED5 JETFUEL E] B M85 ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN 2 WASTE ❑ 2 LEAIEO L_j 99 OVER(DESCRIBE N ITEM O.BELOW) D. IF(Ai)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A S Ill. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A,B.AND C.ANO ALL THAT APPLIES IN BOX O AND E A. TYPE OF 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 5 INTERNAL BLADDER SYSTEM ❑ 95 UN04O N SYSTEM 2 SINGLE WALL ❑ d SINGLE WALL IN A VAULT ❑ 99 OTHER B. TANK ❑ 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS 6 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ T ALUMINUM ❑ 8 lIX]% METHANOL COMPATIBLE W/FRP (PHmery Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 85 UNKNOWN ❑ 99 OTHER C.INTERIOR ❑ I RUBBER UNED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ A PHENOLIC LINING LINING OR ❑ 5 GLASS LINING ❑ 8 UNLINED ❑ ,95 UNKNOWN ❑ 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL7 YES SG/No_ D.EXTERIOR ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP A FIBERGLASS REINFORCED PLASTIC CORROSION 5 CATHODIC PROTECTION ❑ 91 NONE ❑95 UNKNOWN 99 OTHER PROTECTION ❑ E SPILL AND OVERFILL,ete. SPILL CONTMNMENT INSTALLED(YEAR) OVEAR LLEVENTION 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 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL A DOUBLE WALL A U 3 UNED 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 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U B CONCRETE A U T STEEL W/COATING A U 8 100% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODICROTECTION A U 95 UNKNOWN U 99 OTHER D. LEAK DETECTION LEcwaGu MIE uAlc ❑2 u+E 3r+rtras5 3 caNRAlau wrEestmu ❑A aEmiK u 5 Mnou m RAr s9 oTHD1 TIETEmOf1 rESINa KONToen+G reAa raTEc1GR aalloovN V.TANK LEAK DETECTION ❑ 1 ISUAL CHECK ❑ 2 RECONCILIATIONNUAL INVENTORY ❑ 3 VADOZE MONITORING ` AUTOMAnC GAUGING TANK ❑ 5 GROUNO MONITORING ❑8 ANNUALTESTINGTANK 77 CONTINUOUS INTERS ITIAL ❑ 8 SIR ❑ 9 WEEKLY EEGAUGING MANUAL ❑10 TENTHLY TANK ❑ 95 UNKNOWN ❑99 OTHER MONITORING 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 ❑ NO ❑ SUBSTANCE REMAINING —GALLONS INERT MATERIAL 7 THIS FORM HAS SEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT TANK OnNAME DATE (X8SIGNATURE) LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY k JURISDICTION a FACILTY k TANK k �r STATE I.D.# m � 1-51D-17 L�u 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)