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STATE OF CAUFORNIA •••,,;,, STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. EMARKLY L4-INEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ] PERMANENTLY CLOSEDON SITE M ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT e TEMPORARY TANK CLOSURE 8 TANK REMOVED ACILRY NAME WHERE TANK IS INSTALLED: 7 K�✓S C. vG T I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A OWNERS TANK I.D.a B. MANUFACTURED BY: v� C. DATE INSTALLED(MO/DAYNEAR) U�lc D. TANK CAP ALLONS: O II.TANK CONTENTS IFA-1 IS MARKED,COMPL ITEM C. /¢ 062,671, A ❑ 1 MOTOR VEHICLE FUEL ❑ 4 OIL 8. C 1a REGULAR U ED ❑ 3 DIESEL ❑ 6 AVIATION GAS ❑ 2 PETROLEUM O 8o E PTY ❑ I PRODUCT ❑ 1D PREMIU LEADED ❑ 4 GASAHOL ❑ ] METHANOL ❑ 3 CHEMICALPRODUCT 95 UNK WN ❑ 2 WASTE ❑ lc M E UNLEADED 5 JET FUEL ❑ B M65 LEADED 99 OTHER(DESCRIBE IN ITEM D.BELOW) D. IF(0.1)15 NOT MARKED, ENTER NAME OF SUBSTANCE STORE S.#. III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.B,AND C.AND ALL THAT APPLIES IN BOX D AND E [A. YPE OF ❑ I DOUBLE WALL O 3 SINGLE WALL WITH EXTERIOR LINER ❑ 5 INTERNAL BLADDER SYSTEM ❑ 95 UNKNOWN YSTEM 2 SINGLE WALL 4 SINGLE WALL IN A VAULT B9 OTHER TANK BARE STEEL 2 STAINLESS STEEL ❑ 3 FIBERGLASS 4 STEEL CLAD Wl FIBERGLASS REINFORCED PLASTIC ATERIAL 5 CONCRETE ❑ B POLYVINYL CHLORIDE ❑ ] ALUMINUM B 100% METHANOL COMPATIBLEWIFRP maryTank) ❑ 9 BRONZE 10 GALVANIZED STEEL 95 UNKNOWN 99 OTHER TERIOR ❑ 1 RUBBER LINED Q 2 ALKYD LINING ❑ 3 EPDXY LINING O 4 PHENOLIC LINING LINING OR ❑ 5 GLASS LINING j:2!:r- ,UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 10D% METHANOL? YES_ NO— D.EXTERIOR -11 POLYETHYLENE WRAP ❑ 2 COATING CORROSION ❑ 3 VINYL WRAP ❑ d FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION @I NONE ❑95 UNKNOWN O 99 OTHER E.SPILL AND OVERFILL,etc. SPILL CONTAINT INSTALLS ) OVERFILL PREVENTION E IPMENT INSTALLED(YEAR) Iy DROP TUBE YE-S" NO STRIKER PLATE YES_ NO DISPENSER CONTAINMENT YES_ N0=\ IV.PIPING INFORMATION CIRCLE A IFABOVEGROUNDOR U IF UNDERGROUND,BOTH IF APPUCABLE =sm PE A U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER U TION A U 1 SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A095 UNKNOWN A U 99 OTHERAND A U 1 BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A U 4 FIBERGLASS PIPE N A U 5 ALUMINUM A U 6 CONCRETE A U T STEELW/COATING A U 8 100% METHANOL COMPATIBLEW/FRP N A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION AU95 UNKNOWN A U 99 OTHER CTION ❑1 NEOYNGL UNE LE"A ❑2 DNE TIDKrL�ss ❑3 caxrwl:ous NIERSTmu 4 D.Ecmaac uxE 5 AuroLunc Puw DETECTOR TESTND IbMCR11lA UEA DETECTOR EHU1DOlIT1 V.TANK LEAK DETECTION ❑ 99 OTHER 1 VISUAL MANUAL VADOZE AUTOMAT GROUND O ] CONTNUOUSKNTERSTITIAL O 2 RECONCILIATIONORV ❑ 3 MONITORING ❑ 4 GAUGNGIC TANK ❑5 MONNORINGTER ❑ B TESTINGTANK MONITORING ❑ B SIR ❑ 9 TANEKLY K GAUGAINSALO 10 MOT HLY TANK gg5 UNKNOWN O 99 OTHER VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE W-PUCE) 1.ESTIMATED DATE LAST USED(MO/DAYNR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH SUBSTAGE REMAINING _GALLONS INERT MATERIAL] YES ❑ NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT TANK OWNERS NAME (PRIMED 6 SIGNATURE) DATE LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW STATE I.D:# L CmOUNTY» JURISDICTION 0 FACILITY X TANK N � PERMIT NUMBER PERMIT 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 PLAN. FILE THIS FORM WITH THE LOCAL AGENCY IMPLFMFNnur.THF UNnc9r.9nnun CT^" -...,._-_...._--