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STATE OF CAUFORNIA a STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION -FORM BCOMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION T PERMANENTLY CLOSED ONSITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE O B TANK REMOVED f DBA OR FACILITY NAME WHERE TANK IS INSTALLED: I. TANK DESCRIPTION COMPLETE ALL ITEMS– SPECIFY IF UNKNOWN V yv A OWNER'S TANK I.D.i / B. MANUFACTURED BY: C. DATE INSTALLED(MOIDAY/YEAR) � � D. TANK CAPACITY IN GALLONS: / [N� II.TANK CONTENTS IFA-1 IS MARKED,COMPLETE ITEM C. A X MOTOR VEHICLE FUEL ❑ 4 OIL B. C. ❑ 1-REGULAR UNLEADED ❑ 3 DIESEL ❑ 6 AVIATION GAS 2 PETROLEUM O 80 EMPTY 1 PRODUCT ❑ Ib PREMIUM UNLEADED ❑ 4 GASAHOL ❑ T METHANOL Io MIDGRADE UNLEADED ❑ 5 JETFUEL ❑ 8 NO ❑ 3 CHEMICAL PRODUCT ❑ 8S UNKNOWN ❑ 2 WASTE 2 LEADED ❑ 99 OTHER(DESCRIBE IN ITEM D.BELOm D. IF(A 1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S.M: 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 ❑ 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 5 INTERNAL BLADDER SYSTEM ❑ 95 UNKNOWN SYSTEM X2 SINGLE WALL ❑ 4 SINGLE WALL IN A VAULT ❑ 99 OTHER 8, TANK x 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ T ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP (PNmary Twk) ❑ 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 \C__j/B UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WI 100% METHANOL? YES— NO_x D.EXTERIOR ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC CORROSION PROTECTION ❑ 5 CATHODIC PROTECTION 9I NONE ❑ 95 UNKNOWN ❑ 99 OTHER E SPILL AND OVERFILL,BIC. SPILL CONTAINMENT INSTALLED EAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAH) DROP TUBE VES NOX STAIKERPLATE VES 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 01 SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND A 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 T STEEL W/COATING A U 8 100% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 85 UNKNOWN A U 99 OTHER D. LEAK DETECTION1 LEG QL UNE LEAN 2 UNE I(RUNE 3 CWINUMS INiFR5R11A1 4 ELEC NIC LINE 5 AUfOWiIC wla ❑ OEIECTOR ❑ usl1m; MoNTOBmtl IFAK OETECfdV ❑ SNUIODWN 99 OTHER V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 MANUAL I INVENTORY ❑ 3 VADOZE LNG ❑ 4 AUTOMATAUTOMATIC TANK ❑ 5 MON ND DATER ❑ 6 ANNUATESTINGTANK RECONC❑ ? MONITORING INTERSTITIAL ❑ 8 SIR ❑ON 8 TANKLY MANUAL ❑IO MONTHLY TANK g5 UNKNOWN ❑99 OTHER NG VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) 1.ESTIMATED D TE T US (M AV/YR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES ❑ NO❑ SUBSTANCE REMAINING 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 B STATE I.Dl aV1 = I I TTJ 1,ri I o V2 1,51"L-A PERMIT NUMBED PERMIT APPROVED BYIDATE PERMIT EXPIRATION DATE THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPUr-–I)N-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. Ff"lC MUST BE COMPLETED FOR INSTALLATIONS.THIS FORM FORM (6-95)SHOULD BE ACCOMPANIED BY A PLOT P\ FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THF_ FRGROUND STORAGE TANK REGGUU,LAT137,