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�/ � oUnCG4 STATE OF CALIFORNIA �. STATE WATER RESOURCES CONTROL BOARD sy b o UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B 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 8 TANK REMOVED f DBA OR FACILITY NAME WHERE TANK IS INSTALLED: -3-I MGp TSL-L1c K— P(_.AZLt 1 I. TANK DESCRIPTION COMPLETE ALL ITEMS-- SPECIFY IF UNKNOWN A OWNER'S TANK I.D.$ B. MANUFACTURED BY; /YI D069—) tA✓EZUI A)G� C. DATE INSTALLED(MO/DAYNEAR) (( r�� D. TANK CAPACITY IN GALLONS: I ZA DOC) II.TANK CONTENTS IF A-1 IS MARKED,COMPLETE TEM C. A �1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C. Ta REGULAR UNLEADED ❑ 3 DIESEL L_] 6 AVIATIONGAS O 1b PREMIUM UNLEADED ❑ 4 GASAHOL ❑ 7 METHANOL ❑ 2 PETROLEUM ❑ 80 EMPTY �1 PRODUCT ❑ 1c MIDGRADE UNLEADED 5 JET FUEL❑ ❑ 8 M65 ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED ❑ 99 OTHER(DESCRIBE IN ITEM D.BELOW( D, IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S.# Ill. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A,B.AND C.AND ALL THAT APPLIES IN BOX D AND F A, TYPE OF 1 DOUBLE WALL 3 SINGLE WALL WITH EXTERIOR LINER ❑ 5 INTERNAL BLADDER SYSTEM E_] 95 UNKNOWN SYSTEM ❑ 2 SINGLE WALL ❑ 4 SINGLE WALL IN A VAULT ❑ 99 OTHER B. TANK ❑ 1 BARE STEEL 2 STAINLESS STEEL a 3 FIBERGLASS 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W1FRP (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 UNLINED ❑ 95 UyiKNOWN ❑ 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 100'/a METHANOL? YES_ NO_ D.EXTERIOR ❑ 1 POLYETHYLENE WRAP F-1 2 COATING ❑ 3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC CORROSION PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER E.$PILL AND SPILL CONTAINMENT I FI TALLED(YEAR) OVERFILL EVENTION EQUIPMENT INSTALLED(YEAR) DROP TUBE YES NO STRIKER PLATE YES NO DISPE OVERFILL,etc. NSER CONTAINMENT YES NO IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION U 2 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 99 OTHER C. MATERIAL AND A U 1 BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A 04 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL W/COATING A U 8 100% METHANOL COMPATIBLE WIFRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER 1 MECHANICAL LINE LEAK 2 UNE TIGHTNESS 3 CONTINUOUS INTERSTITIAL 4 ELECTRONIC LINE71 5 AUTOMATIC PUMP 99 OTHER D. LEAK DETECTION pETECTOR TESTING MONITORING ❑ LEAK DETECTOR SHUTDOWN ❑ V.TANK LEAK DETECTION 1 VISUAL CHECK ❑ 2 RMANUAL ECONCILIATION '❑ 3 VADMON`IITORING 4 AUTGAUOGINGIC TANK ❑ 5 MOOrONTNORINGTER ❑ 6 TESTINGTANK 7 MONITORING INTERSTITIAL F-18 SIR E7:] 9 WEEK LY MANUAL ❑ 10 MO TINGY TANK F-] 95 UNKNOWN Ll 99 OTHER VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) 1.ESTIMATED DATE LAST USED(MO/OAY/YR) � 2.ESTIMATED OUANT1 Y OF 3.WAS TANK FILLED WITH SUBSTANCE REMAINING GALLONS INERT MATERIAL? THIS FORMS HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT TANK OWNER'S NAME DATEib (PRINTED S SIGNATURE) M5! Ci/�i �, I LOCAL AGENCY USE ONLY THE ST .NUMBER I OMPOSED OF THE FOUR NUMBERS BELOW Y COUNTY# JURISDICTION# FACILITY# TANK# OCi% STATE LCI.# m u 17 8 9 '7 PERMIT NUMBER PERMIT APPROVED BYtOATE 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 ACCOMPANLED BY A PLOT PLAN. FILE THIIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS FORM B (6-95)