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STATE OF CALIFORNIA `w �`% STATE WATER RESOURCES CONTROL BOARD yym� UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM B COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT O 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED EONITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT O 6 TEMPORARY TANK CLOSURE O B TANK REMOVED DBA OR FACILRY NAME WHERE TANK IS INSTALLED: D 1 A- I. TANK DESCRIPTION COMPLETE ALL ITEMS— SPECIFY IF UNKNOWN A. OWNERS TANK I.D.0 Z B. MANUFACTURED BY:'41DQ�d 64a1 (�4i C. DATE INSTALLED(MO/OAY/YEAR) D. TANK CAPACITY IN GALLONS: �.Dt7D II.TANK ////777CONTENTS IFA-1 IS MARKED,COMPLETE ITEM C. A FO MOTOR VEHICLE FUEL E::] 4 OIL S. C. 1. REGULAR UNLEADED O3 DIESEL E::] 6 AVIATION GAS 2 PETROLEUM O SO EMPTY 1 PRODUCT ib PREMIUM UNLEADED O4 GASAMOL Ey ❑ 7 METHANOL ❑ 1e MIDGRADE UNLEADED E::] 5 JET FUEL ❑ 8 M85 ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN 2 WASTE ❑ 2 LEADED O 99 OTHER(DESCRIBE IN NEM D.BELOM D. IF(A1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S.M 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 O 3 SINGLE WALL WITH EXTERIOR LINER ❑ 5 INTERNAL BLADDER SYSTEM ❑ 95 UNKNOWN SYSTEM Pf 2 SINGLE WALL ❑ d SINGLE WALL IN A VAULT ❑ S9 OTHER B. TANK ❑ 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM 6 100% METHANOL COMPATIBLE W/FRP (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER C.INTERIOR ❑ 1 RUBBER LINED ,,F-1 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING LINING OR E] 5 GLASS LINING K,I 6 UNLINED O 95 UNKNOWN ❑ 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 100°6 METHANOL? VES�C NO_ D.EXTERIOR O 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,lIC. SPILL CONTAINMENT IN LLED(YEAR) OVERFILL P ENTION EQUIPMENT INSTALLED(NEAR) DROP TUBE YES_ NO STRIKER PLATE YES NO DISPENSER CONTAINMENTVES NO IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION I; PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL A 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U B9 OTHER C. MATERIAL AND A U 1 BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) 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 U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION1 REca=IME I 2 ME TIEHI ESS 3 CarmnaOUS IrrrERST 4 ELECIR a ME s At9CMATlc PUIF ❑ 9ETECfGP ❑ TEaiBlG ❑ yGN{pgWG LFAK OE1ECTd1 ❑ NM6GWN ❑ 99 OTHER V.TANK LEAK DETECTION 1 VISUAL CHECK ❑ 2 MANUAL INVENT14ECONCILIATIONORY ❑ 3 MONITORING VAZE ❑ 4 GAUGNGAUTOMATIC TANK ❑ 5 MONTORINGGROUND WATER ❑ e ANNUAL TESTINGTANK 7 MON INUOU INTERSTITIAL ❑ 8 SIR ❑ 9 WEEK GAUGING ❑ 10 MOTESTINGHLY TANK ❑ 95 UNKNOWN ❑99 OTHER VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) 1.ESTIMATED DATE LAST USED(MO/DAY/YR) 2.ESTIMATED QUANTITY OF3.WAS TANK FILLED WITH YES ❑ NO ❑ SUBSTANCE REMAINING GALLONS INERT MATERIAL 7 THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT TANK OWNERS NAME DATE (PRINTED 8 BIGNATURET LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION M FACILITY# TANK#DQ T'^! STATE I.D:# C- 7 g'Z9� PERMIT NUMBER PERMIT APPROVED SYMATE 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 T FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING TH IERGROUND STORAGE TANK REGULATIONS FORM B (6-95) �/ V