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• STATE OF CALIFORNIA • STATE WATER RESOURCES CONTROL BOARD = 'cso...... ,c�; UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. 1 MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ' ,SE ONE REM 2 INTERIM PERMIT S CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED O ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ a' 8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: W, I t T I. TANK DESCRIPTION COMPLETE ALL ITEMS_ SPECIFY IF UNKNOWN A OWNERS TANK I.D.a ':�)ZdZ— B. MANUFACTURED BY:C C. DATE INSTALLED(MC/DAY/YEAR) V I D. TANK CAPACITY IN GALLONS: O 00 II.TANK CONTENTS IFA-1 IS MARKED.COMPLETE ITEM C. A ��1 MOTOR VEHICLE FUEL ❑ d OIL B, C. is REGULAR UNL&D® ❑ 3 DIESEL ❑ 6 AVIATION GAS ❑ 2 PETROLEUM ❑ SO EMPTY ��, 1 PRODUCT ❑ ib PREMNM UNLEADED ❑ 0 GASAHOL ❑ 7 METHANOL ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ IC MIDGRADE UNLEADED ❑ 5 JET FUEL ❑ 8 M65 ❑ 2 LEADED ❑ 99 OTHER(DESCRIBE INTEND.BELOW) D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.ASM: 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 �I DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ ❑ 5 INTERNAL BLADDER SYSTEM ❑ 95 UNKNOWN SYSTEM ❑ 2 SINGLE WALL d SINGLE WALL IN A VAULT ❑ 99 OTHER B. TANK ❑ 1 BARE STEEL ❑ 2 STAINLESS STEEL � 3 FIBERGLASS ❑ d STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 8 POLYVINYL CHLORIDE ❑ 7 ALUMINUM (Primary Tank) O ❑ ❑ 8 100% METHANOL COMPATIBLE W/FRP 9 BRONZE 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER C.INTERIOR ❑ I RUBBER UNED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 0 PHENOLIC LINING LINING OR 5 GLASS LINING ❑ 6 UNUNED ❑ 95 UNKNOWN COATING ❑ 99 OTHER IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YESk_ NO_ D.EXTERIOR ❑ I POLYETHYLENE WRAP2 COATING CORROSION ❑ ❑ 3 VINYL WRAP d FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTON ❑ 91 NONE ❑95 UNKNOWN ❑ 99 OTHER E SPILL AND OVERFILL,etc SPILL CONTAINMENT INSTALLED(YEAq) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) DROP TUBE VES 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 2 PRESSURE A U 3 GRAVITY A U d FLEXIBLE PIPING A U 89 OTHER B. CONSTRUCTION A U 1 SINGLE WALL A DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND A U 1 BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)U d FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL W1 COATING PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 8 100% METHANOL COMPATIBLE W/FRP D. LEAK DETECTIONllk1ECXMp�uxE LFAIc ❑2 urE Nnn9KEss ❑3 A U 99 OTHER oETEcroR 1Esnxa ^15 I"r�s1m� ❑1 Occmaxc uxE s Aurawnc ww V.TANK LEAK DETECTION 9E E" �Hu wxn ❑99 OTHER ❑ 1 VISUAL CHECK ❑ 2 RECOOAL CILIATIONINVENTORY ❑ 3 MONAORING d AUTOMATIC C TANK ❑5 GROUND WATER 6 ANNUAL TANK 7 CONTINUOUS INTERSTITIAL MONITORING ❑ TESTING MONITORING ❑ 8 SIR ❑ 9 WEEKLY MANUAL ❑10 MONTHLY TANK ❑ 95 UNKNOWN ❑99 OTHER TANK GAU IN TESTING VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE 1/A 1/E$ ATED DATE LAS�LISED(MOIDAY/YR) .ESTIMATED QUANTITY OF !Y /i SUBSTANCE REMAINI 3.WAS TAN LLED WITH YE� NO GALLONS MATERIAL? THIS FORM HAS BEEN COMPLETED UNDE N TY OF PE U Y,A T TANK OWNERS NAME BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT (PRINIEDL 51(iNATUR ^e< FLgi DATE C orl 0 $ LOCAL AGENCY USE ONLY THE STATE .NUMBER I MPOSED OF THE FOUR NUMBERS BELOW COUNTYN J SDICTION M FACILITY603 TANK N 6 STATE I.D.# m a s ( � p PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICAON- SHOULD BE ACCOMPANIED BY A PLOT P A� FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. FORM C BE COMPLETED FOO INSTALLATI S. THIS FORM LE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE, GROUND STORAGE TANK REGULATIONS FORMS (695)