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W nc� STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD 4'mtf�, "_ d°a UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B _ , 1 - 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 DBA OR FACILITY NAME WHERE TANK IS INSTALLED: 1Z101 j6—r. !S I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A OWNERS TANK I.D.# l/ B. MANUFACTURED BY: C. DATE INSTALLED(MO/DAY/YEAR) D. TANK CAPACITY IN GALLONS: 0;"p II.TANK CONTENTS IF A-1 IS MARKED,COMPLETE ITEM C. A ❑ 1 MOTOR VEHICLE FUEL OIL B. C. la REGULAR UNLEADED ❑ 3 DIESEL ❑ 6 AVIATION GAS a 2 PETROLEUM ❑ 80 EMPTY ❑ 1 PRODUCT ❑ ib PREMIUM UNLEADED ❑ 4 GASAHOL ❑ ] METHANOL ❑ lc MIDGRADE UNLEADED ❑ 5 JET FUEL ❑ 8 M85 ❑ 3 CHEMICALPRODUCT ❑ 95 UNKNOWN 2 WASTE ❑ 2 LEADED 99 OTHER(DESCRIBE IN REM D.BEI.OM D. IF(A1)IS NOT MARKED. ENTER NAME OF SUBSTANCE STORED me C.A S.# 111. 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 LINER ❑ 5 INTERNAL BLADDER SYSTEM ;215 UNKNOWN SYSTEM ❑ 2 SINGLE WALL ❑ 4 SINGLE WALL IN A VAULT ❑ 99 OTHER B. TANK ❑ i BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM O B 100% METHANOL COMPATIBLE W/FRP (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL 5 UNKNOWN ❑ 99 OTHER C.INTERIOR ❑ I RUBBER LINED ❑ 2 ALKYD UNING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC UNING LINING OR ❑ 5 GLASS LINING ❑ 6 UNLINEDI� 95 UNKNOWN E] 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? ?YES— NO_ D.EXTERIOR ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING F-1 3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC CORROSION PROTECTION ❑ 5 CATHODIC PROTECTION Cl 91 NONE5 UNKNOWN ❑ 99 OTHER E SPILL AND OVERFILL,6LC. SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL 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 U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH Aff�g 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 STEEL W/COATING A U B IDD% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION 4-9316 UNKNOWN A U 99 OTHER D. LEAK DETECTION1 McCIM D E LAX 2 LME Twl M 3 CarmwwS IRfER$iITIAL 4 EIEC C UNE s AvrolMTk wNv ❑ OEIECTOR ❑ IMrr G ❑ "W MW UAK CETECTCR ❑ SMRWWX 99 OTHER V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 RECONCILIATIOANUAL N MONITORING ❑ 3 MONIITORING ❑ 4 GAUGING C TANK ❑ 5 MONITORINGOUND TER ❑ 6 TESTING ❑ AUTOMATI 7 CONPNMONITOUROU INTERSTITIAL ❑ 8 SIR ❑ING 9 WEEKLY NK MANUAL E::]10 M SNTHGTINY TANK 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) 1.ESTIMATED DATE LAST USED(MO/DAYNR) 2-ESTIMATED OUANTITY OF 3.WAS TANK FILLED WITH YES O NO❑ SUB STANCEREMAINING GALLONS INERTMATERIAL? 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 (PRINTED A SIGNATURE) LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY# TANK# STATE I.D.# 6 © /Ikg; PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE O / 3 . 80 I O 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 lNgrALLAT16NS, AIS FORM SHOULD BE ACCOMPANIED BY A PLOT PLA `LE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE U- -9GROUND STORAGE TANK REGULATIONS FORMS (6-95) low \llf FOROONBRT