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STATE OF CALIFORNIA s STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B - I COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION �❑ 7 PERMANENTLY CLOSED ON I ONE REM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 8 TEMPORARY TANK CLOSURE v/� 8 TANK REMOVED /S DBA OR FACILITY NAME WHERE TANK IS INSTALLED: �,Sd 6A (im /1'� v 1. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A OWNER'S TANK I.D.• V( B. MANUFACTURED BY: C. DATE INSTALLED(MC/DAY/YEAR) D. TANK CAPACITY IN GALLONS: II.TANK CONTENTS IF A-1 IS MARKED,COMPLETE ITEM C. A 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. REGULAR UNLEADED ❑ 3 DIESEL ❑ 8 AVIATION GAS 2 PETROLEUM ❑ 80 EMPTY ❑ 1 PRODUCT 1b PREMKIM UNLEADED E] 4 GASAHOL ❑ 7 METHANOL ❑ Ic MIDGRADE UNLEADED JET FUEL ❑ 9 M85 ❑ 3 CHEMICALPRODUCT ❑ 93 UNKNOWN ❑ 2 WASTE 2 LEADED 99 OTHER( UCRIBEIN ITEM D.BE-OM D. IF(Al)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A S.k Ill. 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 ❑ 3 SINGLE WALL WITH EXTERIOR UNER ❑ 5 INTERNAL BLADDER SYSTEM ❑ 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 g 5 CONCRETE ❑ 8 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP (PHmary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER C.INTERIOR ❑ 1 RUBBER LINED ❑ 2 ALKYD UNING ❑ 3 EPDXY UNING ❑ 4 PHENOLIC LINING LINING OR ❑ 5 GLASS LINING Jz) 8 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_5a 91 NONE ❑95 UNKNOWN ❑ 99 OTHER E SPILL AND OVERFILL,BIC. SPILL CONTAINMENT INSTALLED EAR) OVERFILL PREVE N OUIPMENT INSTALLED(YEAR) DROP TUBE VEB_ NC ST IKER PLATE YES_ C DISPENSER CONTAINMENT VES_ NO IV.PIPING INFORMATION CIRCLE A IF ABOVEGROUND OR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION AM 2 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION A(p1 SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND 1 BARE STEEL A U '2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A U 4 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U B CONCRETE A U 7 STEEL W/COATING A U B 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 ❑1 � UaE LIO E:j 2 UMIi�>wwrlEss 3 camw�xrusmw ❑4 D.Lcm�a�xc� W 0 s Aur Pua O gg On En V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 TANK RECONCILIATIONORY ❑ 3 MONITORING ❑ 4 GAUGING AUTOMATIC TANK ❑5 MONITORINGUND WATER ❑ 8 TESTING ❑ 7 MONITORINGS INTERSTITIAL ❑ 8 SIR ❑ 9 WEEK GAUGING ❑10 MONTHLY TANK ❑ 95 UNKNOWN ❑99 OTHER TESTING VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-P E) 1.ESTMAU DArTE IAST USED(MCJOAY/YR) 2.ESTIMATED UANNTY OF �/ 3.WAS TANK FILLED WITH YES ❑ P 0 10 I.(,1� SUBSTAN E REMAINING GALLONS INERT MATERIAL 7 JAN THIS FORM HAS BEEN COMPLETED UNDER PEL F PER URY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT TWWt9WHG@S NAME 1 ( 1 , /1� (PRMEDA SKiNATURq JA/I li AA(`a ��' Y +I. M.K� DATE 'IS LOCAL AGENCY USE ONLY THE STATE ID.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW V w„ CO� JURISDICTION 1 FACILITY M I f TANK• STATE I.D.# o 0 PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORMA,UNLESS A CURRENT FORMA HASSEENFILED. FORM C MUST BE COMPLETED FOR INSTALLATIONS.THISPORM SHOULD BE ACCOMPANIED BY A PLOT P RLE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THF 'ERGROUND STORAGE TANK REGULATIONS FORM B (8-95) �� .� �w//_ T?�l l