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• pywc STATE OF CALIFORNIA w STATE WATER RESOURCES CONTROL BOARD s` <y4�O 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 CLOSED ON SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE 8 TANK REMOVED a DBA OR FACILITY NAME WHERE TANK IS INSTALLED: u°�,� I�pOLt4 I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A OWNERS TANK 1.0.f t1w B. MANUFACTURED BY: C. DATE INSTALLED(MO/DAY/YEAR) u D. TANK CAPACITY IN GALLONS: 7 9"av II.TANK CONTENTS IF A•1 IS MARKED,COMPLETE ITEM C. A 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C. le REGUUfi UNLEADED 3 DIESEL ❑ 6 AVIATION GAS ❑ 2 PETROLEUM ❑ 80 EMPTY ❑ 1 PRODUCT ❑ 10 PRQANM UNLEADED g 4 JET FUEL ❑ 7 METHANOL ❑ ❑ ❑ 2 RDE UNLEADED ❑ 99J0 EREPESCa MRTEND.BELOW 5 M85 3 CHEMICAL PRODUCT 95 UNKNOWN 2 WASTE D. IF(A1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A S.N: 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 ❑ I DOUBLE WALL ❑ BL 3 SINGLE WALL WITH EXTERIOR UNER ❑ 5 INTERNAL ADDER SYSTEM ❑ 95 UNKNOWN T�y SYSTEM 1[ 2 SINGLE WALL F-14 SINGLE WALL IN A VAULT ❑ 99 OTHER B. TANK 12 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ B i00% METHANOL COMPATIBLE W/FRP (PAY TMlQ ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER C.INTERIOR ❑ I RUBBER UNED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING LINING OR ❑ 5 GLASS UNING 6 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL YES_ NO— D.EXTERIOR ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC CORROSION PROTECTION ❑ 5 CATHODIC PROTECTION 91 NONE El95 UNKNOWN E:] 99 OTHER E SPILL AND OVERFILL,Ste. SPILLCONTAINMEM INSTALLED FAR) OVER PREVE EQUIPMENT INSTALLED(YEAR) DROP TUBE YES_ NO 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 rUJ2 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION 1 SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL ANDU 1 BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A U 4 FIBERGLASS PIPE CORROSION A 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL W/COATING A U a 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 WMONTORNO LL ❑4 DECOUIE ❑s AIROMATIC PUIi E:199 OTHERNl � OEIECT011 SHui00KH V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 RECONCILIATION RY ❑ 3 MADOZE ❑ONtTORING 4 GAUTOMA1 TANK a 5 GROUNDWATER ROUUGING D W TER ❑ 6 ANSn LTANK ❑ 7 CONTINUOUS INTERSTITIA- ❑ B SIR 9 TANKLGYA MANUAL ❑10 MONTHLY TANK ❑ 95 UNKNOWN ❑99 OTHER TESTING VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE -PLACE) 1.ESTTED ATE LAST USED(MOIOAY/YR) 2.ESTIMA 0 QUANTITY OF 7 3.WAS TANK RILED WITH YES NO� I/1 SUBST CE REMAINING + GALLONS INERT MATERIAL 7 ❑ THIS FORM HAS BEEN COMPLETED UNDER PENH OF P110JURY,AN O THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT TANK OWNER'S NAME (PRINTED 8 SIGNATURE) /�/'IA)-' l/-1V�(M'L"�✓�. � /)}�{�•< D r DATE /Lr' /✓ LOCAL AGENCY USE ONLY THE STATE LD.NU ER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY t) JURISDICTION• FACILITY M TANK k DO STATE I.D.# m = I I I I I I I UWlaivildill PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPU(`-`ON-FORMA,UNLESS A CURRENT FORMA HAS BEEN FILED. FOPMC MUST BE COMPLETED FOR INSTALLATIONS. THIS FORM SHOULD BE ACCOMPANIED BY A PLOT P' FlLE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE -RGROUND STORAGE TANK REGULATIONS /, / FORM B (6-95) >•w �I m 6 v,