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STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD `••• .. ` UNDERGROUND STORAGE TANK PERMIT APPLICATION• FORM B • ` a COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. `•I•o. MARK ONLY 1 NEW PERMITNEWAL PERMIT ❑ 3 RE ❑ 6 CHANGE OF INFORMATION ONE ❑ 7 PERMANENTLY CLO Y TE REM ❑ 2 INTERIM PERMIT ❑ AMENDED PERMIT E] 9 TEMPORARY TANK CLOSURE ❑ x TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: YEA D _ �tv bN 0 13 6bolo �Bu I. TANK DESCRIPTION COMPLETE ALL ITEMS— SPECIFY IF UNKNOWN A. OWNER'S TANK I.D.A U 0I-&IOL•JIL) I iI," B. MANUFACTURED BY: _ C. DATE INSTALLED(MO/DAVHEAR) 411 �UTpL �O� INF-I� D. TANK CAPACITY IN GALLONS: to poo ILTANKCONTENTS IFA-11S MARKED,COMPLETE ITEM C. A. 1 MOTOR VEHICLE FUEL ❑ % OIL B. C. I&REGULAR UNLEED 3 DIESEL ❑ S AWATXONGAS ❑ 2 PETROLEUM ❑ 90 EMPTY ,� 1 PRODUCT ❑ 10PREMIUM A GASAHOL ❑ 7 METHANOL ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 UNLEADED 0 5 JET FUEL W OTHER (DESCRIBE IN ITEM D. BELOW) D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C. Ill. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.B,AND C.AND ALL THAT APPLIES IN BOX D AND A. TYPE OF 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER 0 95 UNKNOWN SYSTEM ❑ 2 SINGLE WALL ❑ A SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER S. TANK ❑ i BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS A STEEL CUD WI FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ e POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 9 10D% METHANOL COMPATIBLE WIFFIP (PdmAryTw*) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNIWOWN ❑ 99 OTHER ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ A PHENOLIC LINING C INTERIORLINING ❑ 5 GLASS LINING ," UNLINED ❑ 95 UNKNOWN ❑ w OTHER IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL 7 YES— NO— D.CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP 4W FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE 95 UNKNOWN ❑ 99 OTHER E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(NEAR) �1 OVERFILL PflEVENTIDN EQUIPMENT INSTALLED(YEAR) IV.PIPING INFORMATION CIRCLE A IFASOVEGROUNDOR U IF UNDERGROUND,BOTH IFAPPLICABLE A. SYSTEM TYPE A U 1 SUCTION A*F`z PRESSURE A U 3 GRAVITY A U oo OTHER B. CONSTRUCTION A U 1 SINGLE WALL A 072 DOUBLE WALL A U 3 LINED TRENCH A U 96 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 I1#A FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U S CONCRETE A U 7 STEEL WICOATING A U S 100% METHANOL COMPATIBLE WIFRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHO91CPROTECTION A U 95 UNKIND A U 99 OTHER D. LEAK DETECTION ❑ 1 AUTOMATIC LINE LEAK DETECTOR 2 LINE TIGHTNESS TESTING MONOORNG ❑99 OTHER V.TAbK LEAK DETECTIO 1 VISUAL CHECKNVENTORV RECONCILIATION ❑ 3 VADOZE MONITORING AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING S TANK TESTING INTERSTITIAL MONITORING ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION 1.ESTIMATED DATE LAST USED(MO/DAY/YR) 2.ESTIMATED OUANTITY OF 3.WAS TANK FILLED WITH SUBSTANCE REMAINING GALLONS INERT MATERIAL YES ❑ NO[:j THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANTS i&.V 1 �_I IOR.KreO a sK.a LOCAL AGENCY USE ONLY THE STATE I.D.NUMBERS COMPOSED OF THE FOUR N LOW COUNTY x JURISDICTION x FAC � TANK x O STATE I.D.# = � rTTt �I1 PERMIT NUMBER PERMITAPPROVED BYIDATE PERMIT EXPIRATION LDATE THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. FILE THIS FORM WITH THF'1CAL AGENCY IMPLEMENTING THE UNDERGROUND STOP -'TANK REGULATIONS A-3-1 q FORM B (12.911 `' FOROOIIHM