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�. STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD ey R UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B I COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED O $IT ONE TEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 8 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED U DBA OR FACILITY NAME WHERE TANK IS INSTALLED: c,-T I. TANK DESCRIPTION COMPLETE ALL ITEMS— SPECIFY IF UNKNOWN A OWNER'S TANK I.D.M .Z 2 B. MANUFACTURED BY: C. DATE INSTALLED(MOIDAY/YEAR) Nlj�'S'�cwvg I D. TANK CAPACITY IN GALLONS: II.TANK CONTENTS IFA-1 IS MARKED.COMPLETE ITEM C. p Z?t MOTOR VEHICLE FUEL ❑ 4 OIL B. C. ❑E�II 1a REGULAR UNLEADED ❑ 3 DIESEL ❑ 6 AVIATION GAS ❑ 2 PETROLEUM ❑ 80 EMPN 1 PRODUCT L_i•1b PREMIUM UNLEADED ❑ 4 GASAHOL ❑ 7 METHANOL ❑ tC MIDGRADE UNLEADED ❑ 5 JET FUEL ❑ 8 M85 ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED ❑ 99 OTHER(DESCRIBE IN ITEM D.SELLA D. IF(Al)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A S.# 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 AV, 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 ❑ 1 BARE STEEL ❑ 2 STAINLESS STEEL �Kj 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 6 100% METHANOL COMPATIBLE W/FRP (Primary Twk) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER C.INTERIOR ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING LINING OR jg-5 GLASS LINING ❑ 6 UNUNED ❑ 95 UNKNOWN ❑ 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES�L NO— D.EXTERIOR ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC CORROSION PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE ❑95 UNKNOWN ❑ 99 OTHER SPILL CONTAINMENT INSTALLED(YEAR) OVERFlLLPREVENTIONEOUIPMENT INSTALLED(YEAR) E.SPILL AND OVERFILL,MC. DROP TUBE YES j-&— 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 2 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WWALL 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)AQ4 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL WICOATING 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 D. LEAK DETECTION t 1ECRN&cu uxE LEAIc 2 I#+E TIExRass ❑3 conrNuas N1ERslnw 4 NECTRONIC uNe 5"Mo =11 ❑ 99 GTHER OEIEm011 TESINE MONTORN3 UA&f1ElECTOR 91V1007M V.TANK LEAK DETECTION �}J ❑ 1 VISUAL CHECK ❑ 2 RECONCILIATIONINVENTORY ❑ 3 MAONNIITORING JD 4 GAUGINAUTOMATIC TANK ❑5 MON MONITOOUND RING ❑8 TE�NGTANK 7 MONITORING INTERSTITIAL ❑ 8 SIR ❑ 9 TANKL MAIINGAL E:] 10 M SNTHGTINY TANK ❑ 95 UNKNOWN ❑99 OTHER VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE UM-PLACE) _(IA 1.E ATED DATE LAST US (MO/DAY/YR) 2.ESTIMATE ANRTY OF 3.W K FlLLED WITH Y NO SUBST CE REMAINING GALLONS INERT MATERIAL? THIS FORM HAS BEEN COMPLETED LIN D R TY OF PEPdq Y,AN91 TO ST OF MY KNOWLEDGE,IS TRUE AND CORRECT TANK OWNER'S NAME DA (PRIWM&SIGNATURE) L 'J l//TE O l / 9c'- 04 LOCAL AGENCY USE ONLY THE STATE .NUMBER 194POSED OF THE FOUR NUMBERS BELOW COUNTY# JUkL8bICTION# FACILITY#0 5776 TANK# STATE I.D.# m = a l `f d d I F 1.2 PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE 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 INSTA,I A ONS THIS FORM SHOULD BE ACCOMPANIED BY A PLOT PLWLE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE&GROUND STORAGE TANK REGULATKRIS FORM B (6-95)