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4 STATE OF CALIFORNIA 0 ^^` `�Ooi STATE WATER RESOURCES CONTROL BOARD o 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 SIT ONE REM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT > ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: aE S :- ,�c fIC� j� p O . 1jl Z� I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN O A OWNER'S TANK I.D.# 3 B. MANUFACTURED BY: G DATE INSTALLED(MO/DAY/YEAR) O^ 1 D. TANK CAPACITY IN GALLONS: .p C9 F..V II.TANK CONTENTS IFA-1 IS MARKED,COMPLETE ITEM C. A CK 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C. ❑ 1a REGULAR UNLEADED ® 3 DIESEL ❑ 6 AVIATION GAS ❑ 2 PETROLEUM E] 80 EMPTY I PRODUCT ❑ 1b PREMIUM UNLEADED ❑ 4 GgSAHOL ❑ 7 METHANOL ❑ 3 CHEMICALPRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ Ic MIDGRADE UNLEADED ❑ 5 JET FUEL ❑ B M85 ❑ 2 LEADED ❑ 99 OTHER(DESCRIBE IN ITEM 0.BELOW) D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S.#: III. TANK CONSTTRIUCTION 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 F-'] 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 ❑ 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS F V 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER C.INTERIOR ❑ I RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING LINING OR ❑ 5 GLASS LINING Ex 6 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER COATING IS UNING MATERIAL COMPATIBLE WITH 10016 METHANOL? YES— NO— D.EXTERIOR ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ( 4 FIBERGLASS REINFORCED PLASTIC CORROSION R-r PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE ❑95 UNKNOWN ❑ 99 OTHER E.SPILL AND OVERFILL,BtC. SPILL CONTAINMENT NSTALLED(YEAR) OVERFIL P EVENHUN EQUIPMENT INSTALLED(YEAR) DROP TUBE YES NO SRI R PLATE VES NO DISPENSER CONTAINMEN V S NO IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U I SUCTION A(q 2 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION A U I SINGLE WALL ACV 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND A U I 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 I MECIWI A NNE IFAK 2 LINE TI9 WM 3 CCMINUOUS INIFA4IRML 4 EIECfRGNIC UNE 5 AVrOMAi1C PUMP D. LEAK DETECTION ❑ CETECTOR ❑ TEsr1w ❑ Mollrr MG LEAN 9ETEC10R DRRWWN ❑ 99 OTHER V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 RECONCILIATIONORV ❑ 3 MONITORING4 GAUD AUTOMATIC TANK ❑5 MONITORING GROUND TER ❑ 8 TESTINGTANK rV 7 CONTINUOUS MONITORING INTERSTITIAL ❑ B SIR ❑ 9 TgNEK GAUGING u 10 MOTESTINGHLY TANK ❑ 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) 1.ESTIMATED DATE LAST USED(MO AY/YR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES Pn NO ❑ a ._ q SUBSTANCE REMAINING 00 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 B SIGNATURE( LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY# TANK#007 STATE I.D.# L�U .3 g -71110 11 PERMIT NUMBER IFERMIT APPROVED BYIDATE PERMIT EXPIRATION DATE THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORMA HAS BEEN FILED. FORM C MUST BE COMPLETED FOR INSTALLATIONS. THIS FORM SHOULD BE ACCOMPANIED BY A PLOT P ILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE GROUND STORAGE TANK AEG I}Q,,N/$ 'J / FORM B -95) q `I , • /s � n n'//�n� l '1 -N "7 � jyZ/'q I�(All Fi SAP C�r N �)n[ 1/lL�nh,(�f /I//LOJU/� a rIA 1 1 / 9