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W e« STATE OF CAUFORNM STATE WATER RESOURCES CONTROL BOARD _ ~ 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 ❑ ? PERMANENTLY CLOS ON ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: l*i Z ll� I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A OWNERS TANK I.D.Y B. MANUFACTURED BY: C. DATE INSTALLED(MOIDAY/YEAR) D. TANK CAPACITY IN GALLONS: II.TANK CONTENTS IF A-1 IS MARKED,COMPLETE ITEM C. A 1 MOTOR VEHICLE FUEL E] le REGULAR UNLEADED a OIL S. C. 3 DIESEL ❑ 8 AVIATION GAS 1b PREMIUM UNLEADED ❑ 4 GASAHOL ❑ ? METHANOL 2 PETROLEUM ❑ BO EMPTY i PRODUCT ❑ 1L MOGRADE UNLEADED5 JETFUEL ❑ 8 M85 ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED El 99 OTHER(DESCRIBE W REM D.BELOW) D. IF(Al)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A S. III. TANK CONSTRUCTION MARK ONE NEM ONLY IN BOXES A S.AND C.AND ALL THAT APPLIES IN BOX D AND E A. TYPE OF m 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 ❑ 1 BARE STEEL ❑ 2 STAINLESS STEEL 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE T ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP (Pill—y T-k) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER C INTERIOR ❑ 1 RUBBER UNED ❑ 2 ALKYD LINING ❑ 3 EPDXY UNING ❑ 4 PHENOLIC LINING LINING OR ❑ 5 GLASS LINING 6 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER COATING IS UNING MATERIAL COMPATIBLE WITH 100% METHANOL? YES— NO— D.EXTERIOR ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC CORROSION PROTECTION ❑ 5 CATHODIC PROTECTION'�S 91 NONE ❑95 UNKNOWN ❑ 99 OTHER Cs E SPILL AND OVERFILLMG, SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL REVENTION EQUIPMENT INSTALLED(YEAH) L+ DROPTUBE YES NO_ STRIKER PLATE YES NO DISPENSER CONTAINME ES NO IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND,BOTH IFAPPUCABLE 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 UO2 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 4 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U T STEEL W/COATING A U B 100% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHO CPROTECTION A U 95 UNKNOWN A U 99 OTHER 1 IEfJINAGLL UE LEAN 2 lLE 11911fN:S5 3 CCNfWUg18 NIB61111AL 1 EIECROMC LWE 5 ABfO =RLP D. LEAK DETECTION ❑ ❑ TEsnKLTpNp 1LAx oETEDTaa snRooxll ❑ 99 OTHER V.TANK LEAK DETECTION �/�/��-� 1 VISUAL CHECK ❑ 2 MANUAL INVENTORY ❑ 3 ATION MONITORING ��`4 GAUGING AUTOMATIC TANK ❑5 MONITORING GROUNDpO �GATER ❑ 8 GTANK 1 CONTINUUOUG ITI INTERSTAL ❑ B SIR ❑ 9 WEEKLY LY MANUAL E]10 MONTHLY TANK ❑ 95 UNKNOWN E:]99 OTHER MNITORINTING VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) 1.ESTIMATED DATE LAST USED(MO/DAY/YR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH VES [-] NO ❑ SUBSTANCE REMAINING GALLONS INERT MATERIAL 7 THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT TANK OWNERS NAME DATE 1PRNTED A 616NATURE_ _ LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY N JURISDICTION N FACILITY M TANK N STATE I.D:# m4�1 11 PERMIT NUMBER PERMIT APPROVED BY/OATE 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 INSTALLATIONS.THIS FORM SHOULD BE ACCOMPANIED BY A PLOT PLT" TLE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE V"- RGROUND STORAGE TANK REGULATIONS FORM 5 (6415) e� .� LO-20-41 1�p