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STATE OF CALIFORNIA ......s roe STATE WATER RESOURCES CONTROL BOARD a UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM, MARK ONLY 1 NEW PERMIT a 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOS ITE ONE ITEM F7 2 INTERIM PERMIT 4 AMENDED PERMIT El 6 TEMPORARY TANK CLOSURE O 8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: i ozz.. / —m I. TANK DESCRIPTION COMPLETE ALL ITEMS-- SPECIFY IF UNKNOWN A OWNER'S TANK I.D.>t B. MANUFACTURED BY:,-114s/F/'+dgG C- DATE INSTALLED(MO/DAYNEAR) D. TANK CAPACITY IN GALLONS: II.TANK CONTENTS IF A-1 IS MARKED,COMPLETE ITEM C. A 1 MOTOR VEHICLE FUEL 4 OIL B, Ca REGULAR UNLEADED 3 DIESEL 6 AVIATION GAS 2 PETROLEUM UNLEADED 4 GASAHOL lb PREMIUM 7 METHANOL 80 EMPTY1 PRODUCT Q LJ lc MIDGRADE UNLEADED {,{'� 5 JETFUE 3 CHEMICAL PRODUCT 95 UNKNOWN 2 WASTE L-1 L 6 M 85 2 LEADED 99 OTHER(DESCRIBE IN ITEM D.BELOW) D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C_A.S.sf 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 Ej 3 SINGLE WALL WITH EXTERIOR LINER 5 INTERNAL BLADDER SYSTEM Ej 95 UNKNOWN SYSTEM � 2 SINGLE WALL 4 SINGLE WALL IN A VAULT 99 OTHER B. TANK 1 BARE STEEL 2 STAINLESS STEEL 3 FIBERGLASS 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL 5 CONCRETE ID 6 POLYVINYL CHLORIDE 7 ALUMINUM 8 100% METHANOL COMPATIBLE W/FRP (Primary Tank) ❑ 9 BRONZE 10 GALVANIZED STEEL Q 95 UNKNOWN a 99 OTHER C.INTERIOR ❑ 1 RUBBER LINED 2 ALKYD LINING O 3 EPDXY LINING ❑ 4 PHENOLIC LINING LINING OR 5 GLASS LINING 6 UNLINED F1 95 UNKNOWN F-1 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES Ae!�'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 INSTALLED(YEAR) OVERFILL f,'REVENTION EQUIPMENT INSTALLED(YEAR) DROP TUBE YES NO STRIKER PLATE YES kk��-- NO DISPENSER CONTAINMENT YES NO IV. PIPING INFORMATION CIRCLE A IF ABOVEGROUND 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 A5Z DOUBLE WALL A U 3 LINED 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'11-/4 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 DETECTION f',1 MECHANICAL LINE LEAK 2 LINE TIGHTNESS 1'3 CONTINUOUS INTERSTITIAL �4 ELECTRONIC LINE [7 1 5 AUTOMATIC PUMP a rD. LEAK DETECTION OTHER ''•� DETECTOR TESTING I -I MONITORING LEAK DETECTOR I-J SHUTDOWN V.TANK LEAK DETECTION 1 VISUAL CHECK 1 2 MANUAL RECONCILIATION MONITORING 3 VADOZE MONIITORING `-'-'Y4 GAUGINGIC TANK E 5 GROUND MONITORING TESTING 6 ANNUATESTINGTANK 7 CONITQAING INTERSTITIAL ❑ 8 SIR 9 TANEKGAUGINUAL E] 10 MONTHLY TANK 95 UNKNOWN � 99 OTHER TESTING 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 C�] NO SUBSTANCE REMAINING GALLONS INERT MATERIAL? 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 6 SIGNATURE) LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY# TANK# ��- STATE I.D.# m g PERMIT NUMBER PERMIT APPROVED BYIDATE PERMIT EXPIRATION UA TE 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 5 (6-95)