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`pol STATE OF CALIFORNIA 4A— MARK STATE WATER RESOURCES CONTROL BOARDUNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM.ONLY ❑ I 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 ❑ B TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: 7- .�•�� b� I. TANK DESCRIPTION COMPLETE ALL ITEMS— SPECIFY IF UNKNOWN A OWNER'S TANK 1.D.Y P.4 B. MANUFACTURED BY: �I r C. DATE INSTALLED(MC/DAY/YEAR) D. TANK CAPACITY IN GALLONS: DOLT II.TANK CONTENTS IFA-11S MARKED,COMPLETE ITEM C. p ❑ I MOTOR VEHICLE FUEL 4 OIL B.y---� O. 1a REGULAR UNLEADED 3 DIESEL E] 6 AVIATION GAS ❑ 2 PETROLEUM ❑ SO EMPTY 1 PRODUCT ❑ 1b PREMIUM UNLEADED 4 GASAHOL ❑ 7 METHANOL ❑ 3 CHEMICALPRODUCT ❑ B5 UNKNOWN ❑ 2 WASTE ❑ Ic MIDGRADE UNLEADED ❑ 5 JETFUEL ❑ 8 MSS ❑ 2 LEADED 99 OTHER(DESCRIBE IN ITEM D.BELOW) D. IF(Al)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED Y O/ 'd C.A S.# 111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.B,AND C,AND ALL THAT APPLE/s IN BOX D AND E A. TYPE OF ❑ 1 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 COMPATISLE WIFRP (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL 'qC] 95 UNKNOWN ❑ 99 OTHER C.INTERIOR ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING LINING OR ❑ 5 GLASS LINING ❑ 8 UNLINED95 UNKNOWN F-] 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL7 �Y"ETS_ NO_ D.EXTERIOR ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC CORROSION PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE UNKNOWN ❑ 99 OTHER E SPILL AND OVERFILL,BLD. 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 I SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A&P35 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 8 100% METHANOL COMPATIBLE WIFRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION *Z55?UNKNOWN A U 99 OTHER D. LEAK DETECTION 01 MECXN4GL LNE IFA(( ❑2(INE TGMNEEs 3 CCIRNUM NIFRSTMNE Q 4 ELECIRONC UNE SA PUMP OI.0�L.'• Yy�' yy.� DETEGTCR TE819M MONTDPNG LE1N OETEDTC(1 SXUIDOWN V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 RECONCILIATIONNUAL INVENTORY ❑ 3 MONITORING ❑ 4 AUTOMATGAUGING MONITORING TANK ❑ 5 GROUND MONTORINGTER ❑8 TESTING ❑ 7 CONTINUOUS INTERSTITIAL ❑ B SIR ❑ B WEEKLYTANK UMANUAL ❑10 MONTHLY TANK 95 UNKNOWN ❑99 OTHER TESTING V1.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) 1.ESTIMATED DATE LAST USED(MOIDAYNR) 2 ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES ❑ NO O SUBSTANCE REMAINING GALLONS INERT MATERIAL 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# a-'r STATE I.D.# m �fj 6 17 1 U 3 PERMIT NUMBER PERMIT APPROVED BV/DATE PERMIT EXPIRATION DATE rj 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 INSTAALLATIO THIS FORM SHOULD BE ACCOMPANIED BY A PLOT PLAN._ FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE 1' RGROUND STORAGE TANK REGULATIONS FORM B (6-95) 1lftd