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�.. STATE OF CALIFORNIA -ftw •`�� STATE WATER RESOURCES CONTROL BOARD m�. �g UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM B COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ONSITE ONE REM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 6 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: 1.21,:21 64"ae (, , I. TANK DESCRIPTION COMPLETE ALL ITEMS— SPECIFY IF UNKNOWN A OWNER'S TANK I.D.P / B. MANUFACTURED BY: L/ C. DATE INSTALLED(MODAYNEAR) D. TANK CAPACITY IN GALLONS: II.TANK CONTENTS IF A-1 IS MARKED,COMPLETE ITEM C. A ❑ I MOTOR VEHICLE FUEL 4 OIL B. C. 1# REGULAR UNLEADED ❑ 3 DIESEL ❑ 6 AVIATION GAS ❑ 2 PETROLEUM E:380 EMPTY ❑ 1 PRODUCT ❑ lb PREMIUM UNLEADED ❑ 4 GASAHOL ❑ 7 METHANOL ❑ 8 M85 3 CHEMICALPRODUCT [:3 95 UNKNOWN 2 WASTE 0 £ML RADE UNLEADED ❑ SADEDJOTTHER(DESCR❑IBE IN REM D.BELOW) D. IF(Al)IS NOT MARKED. ENTER NAME OF SUBSTANCE STORED QL C. .S-99'. III. 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 ❑ 5 INTERNAL BLADDER SYSTEM ❑ 95 UNKNOWN SYSTEM ❑ 2 SINGLE WALL ❑ 4 SINGLE WALL IN A VAULT ❑ 99 OTHER B. TANK � BARE STEEL [72 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP (P"-ry Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER C.INTERIOR ❑ 1 RUBBER UNED ❑ 2 ALKYD LINING ❑ 3 EPDXY UNING ❑ 4 PHENOUC LINING LINING OR ❑ 5 GLASS UNING ❑ 6 UNUNED 95 UNKNOWN ❑ 99 OTHER COATING 1S UNING MATERIAL COMPATIBLE WITH 100% METHANOL? %_ NO— D.EXTERIOR ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC CORROSION PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE95 UNKNOWN E:] 99 OTHER E.SPILL AND OVERFILL,GLC. SPILL CONTAINMENT INSTALLED(YEAR) O FILL PREVENTION EQUIPMENT INSTALLED(YEAR) DROP TUBE YES_ NO_ STRIKER 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 1 SUCTION A U 2 PRESSURE A.9W3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION 1 SINGLE WALL A U 2 DOUBLE WALL A U 3 UNED 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 U 4 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 S L W/COATING A U 8 100% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION j 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION ❑1 RECH 1 LINE LEAK ❑2 UNF TMM m ❑3 CONfIXLtlU4 NTER3TRML M 4 ElECTRIX#C UNE ❑5 A.T .PUW ❑ 99 OTHER bETEOTOR MONTOn MVING M9 Um OETECT011 91UTWVN! V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 RRECONCILIATION UAL INVENTORY ❑ 3 VAOZEMONIITORING ❑ 4 AUTOMATIGAUGINGC TANK ❑5 MON TORINGOUND �R ❑ 6 ANNUALTESTING ❑ 7 MONITORING INTERSTITIAL ❑ B SIR ❑ 9 TANKCGAUGINGAL ❑10 MONTHLY TANK 5 UNKNOWN ❑99 OTHER VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PUCE) 1.ESTIMATED DATE USED O/O NR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH /07,49c 1SUB STA NCE REMAINING _GALLONS INERT MATERIAL? YES O N THIS FORM HAS BEEN' COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT TANK OWNER'S NAME DATE (PRINTm SSN3NATURE) LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW 5d COUNTY# JURISDICTION# FACILITY# TANK# STATE I.D.# 5H I 12 3 /6 PERMIT NUMBER I FIERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE q/ 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 I ALLATIONS.THIIS FORM SHOULD BE ACCOMPANIED BY A PLOT PLD 'LE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE U' `GROUND STORAGE TANK REGULATIONS FORM B (6.95) `ol Iftw FOROD3413,1V