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W STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD M1'¢ UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM B �� =° COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ONSITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED Oq DBA OR FACILITY NAME WHERE TANK IS INSTALLED: v AP r7T,&"' Gq Gp I. TANK DESCRIPTION COMPLETE ALL ITEMS— SPECIFY IF UNKNOWN A OWNER'S TANK I.D.# Z, B. MANUFACTURED BY: L M C. DATE INSTALLED(MOIDAY/YEAR) v, D. TANK CAPACITY IN GALLONS::" II.TANK CONTENTS IF A-1 IS MARKED,COMPLETE ITEM C. �� A, 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C. 18 RMUL4R UNLEADED ..y 3 DIESEL ❑ 6 AVIATION GAS ❑ 2 PETROLEUM ❑ 80 EMPTY I PRODUCT ❑ ib PflEMIUM UNLEADED u�`d GASAHOL ❑ 7 METHANOL ❑ 8 M85 3 CHEMICALPRODUCT ❑ 95 UNKNOWN ❑\Y! WASTE O 2 McADEDE UNLEADED O 99 OTHER(DESCRJET FUELIBE IN ITEM D.BELOM D. IF(A7)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.C.A S.0: 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 F-11 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 5 INTERNAL BLADDER SYSTEM I71 95 UNKNOWN SYSTEM F-12 SINGLE WALL ❑ 4 SINGLE WALL IN A VAULT ❑ 99 OTHER T B. TANK ❑ 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE O 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP (PTIm6ry Tmk) ❑ 9 BRONZE ❑ 10 GALVANIZED STEELCS%95 UNKNOWN ❑ 99 OTHER C.INTERIOR ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING LINING OR ❑ 5 GLASS UNING ❑ 6 UNLINED 95 UNKNOWN ❑ 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? 5— NO— D.EXTERIOR ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC CORROSION PROTECTION ❑ 5 CATHODICPROTECTION ❑ 91 NONE95 UNKNOWN ❑ 99 OTHER E SPILL AND OVERFILL,lIC. SPILL CONTAINMENT INSTALLED(YEAR) OV FlLL 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 d7 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL A U 2 DOUBLE WALL A U 3 UNED TRENCH CA 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 STE W/COATING A U 8 100% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION 5 UNKNOWN A U 99 OTHER D. LEAK DETECTION ' KTCH�Nut UK IFAK 2 UK lwxrxEss 3 camlM/ous IxreRslma 4 uEcma4c UK5 Auro =MW ❑ OET um ❑ wsm ❑ 9oMT lw LFAI(OEiEOTOR ❑ 41U190WN ❑ 99 OTHER V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK 2 RECONCI ATIONORY ❑ 3 MONITORING ❑ 4 GAUVADOZEAUTD NG C TANK E:]5N TORINGWATER TESTINGTANK ❑ 7 CONTINUOU L INTERSTITIAL B SIR ❑ 9 TANKAU GY INGAL ❑10 TSNTHGY TANK ❑ 95 UNKNOWN 99 OTHER VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PUCE) 1.ESTIMATED DATE USE (M R) 2.ESTIMATED QUANTITY OF ,D 3.WASTANK FlLLED WITH L o( SUBSTANCE REMAINING GALLONS IN MATERIAL? YES ❑ N THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CO ECT TANK OWNER'S NAME DATE (PRINTED8 SIO TORE) LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY# TANK# G,� STATE I.DN ® Z 6 O W v/I PERMIT NUMBER PERMIT APPROVED BYIDATE PERMIT EXPIRATION DATE 1 Z qjq 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 PI FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE?RGROUND STORAGE TANK REGULATIONS FORM B (6-95) L�