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%Ni '40d a, r STATE OF CALIFORNIA s STATE WATER RESOURCES CONTROL BOARD sN UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B =� ( COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ❑ i NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION a 7 PERMANENTLY CLOSED ON SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED O DBA OR FACILITY NAME WHERE TANK IS INSTALLED: I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A OWNER'S TANK I.D.M 'i - B. MANUFACTURED BY: v C. DATE INSTALLED(MOMAYNEAR) v. D. TANK CAPACITY IN GALLONS: �� pip Z> II.TANK CONTENTS IFA-1 IS MARKED,COMPLETE ITEM C. A ❑ 1 MOTOR VEHICLE FUEL 4 OIL B. C. 1a REGULAR UNLEADED E] 3 DIESEL E] 6 AVIATIONGAS ❑ 2 PETROLEUM 80 EMPTY U 1c MKIGRADE UNLEADED ❑ 1D PREMIUM UNLEADED ❑ 4 GASAHOL E:] 7 METHANOL u ❑ 5 ❑ET FUEL 8 M85 ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN 2 WASTE ❑ LEADED Mag OTHER(DESCRIBE N ITEM O.BELOM D. IF(&I)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED ClAtPfieOAL ^I C.A S.R III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.B,AND C,AND ALL THAT AP IES IN BOX D AND E A. TYPE OF ❑ I 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 I BARE STEEL ❑ 2 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 (Primary TMII) ❑ 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 ❑ 6 UNLINED 95 UNKNOWN ❑ 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 1009A METHANOL? B_ NO— D.EXTERIOR ❑ I POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC CORROSION PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE95 UNKNOWN ❑ 99 OTHER E SPILL AND OVERFILL,e[0. SILL 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 I SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND A X71 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 8 100% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER U D. LEAK DETECTION ❑i MECNN UNE EV( NE?GNI W CGYIIMIWS INIlM7IIUL EIECIROXIC UNE G =PVI® O 011 ❑2 Ums" 3 MONrORmO 4 UT S MOR ❑5 AUIsNuroowx OTHER U Li V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 RECONCILIATION IINVENTORY ❑ 3 MONOITORING ❑ 4 GAUL NG AUTOMATIC TANK ❑5 MON TORING�R ❑8 7�E5TINGTANK ❑ 7 CONTINUOUS INTERSTITIAL O B SIR E] 9gKGANAL ❑10 MONTHLY TANK g5 UNKNOWN 99 OTHER MONITORING T VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) 1.ESTIMATED DUSE (MO/DAV/YR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH O 9 SUBSTANCE REMAINING 0 GALLONS INERT MATERIAL? YES ❑ NO ATE ❑ 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# G j STATE I.D:# ® o o 2 b/ PERMIT NUMBER PER MIT APPROVED BY/DATE PERMIT EXPIRATION DATE (_ .yip 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 INSTALLATIONS.THIS FORM SHOULD BE ACCOMPANIED BY A PLOT PL/- BILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE I -RGROUND STORAGE TANK REGULATIONS FORMS (6.95) `0 4111109