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STATE OF CALIFORNIA 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 ❑ 7 PERMANENTLY CLOSED ON SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: 5k,)[A CAL @q E%C "W /7) LA ✓•fl rt i' `4�0 La I'!1 /'L 60L I TAMK nFSCRIPTInm rnum FTP Al ITFMR_ SPECIFY IF UNKNOWN A OWNER'S TANK I.D.# (�'/ P C. ❑ la REGULAR UNLEADED ❑ 3 DIESEL ❑ 6 AVIATION GAS © lb PREMIUM UNLEADED ❑ 4 GASAHOL ❑ 7 METHANOL B. MANUFACTURED BY: AlodEeV ® 1 PRODUCT C. DATE INSTALLED(MOIDAYNEAR) O6 .,;-� jJ D. TANK CAPACITY IN GALLONS: 2O UUC% II TANK CONTENTS IF A.1 IR MARKED_ COMPLETE ITEM C. A ® 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C. ❑ la REGULAR UNLEADED ❑ 3 DIESEL ❑ 6 AVIATION GAS © lb PREMIUM UNLEADED ❑ 4 GASAHOL ❑ 7 METHANOL ❑ 2 PETROLEUM ❑ 80 EMPTY ® 1 PRODUCT ❑ 1C MIDGRADE UNLEADED ❑ 5 JET FUEL ❑ 8 M85 ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED ❑ 99 OTHER (DESCRIBE IN ITEM D. BELOW) D. IF (A.1) IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C. A S. #: 111 TANK CnNSTRMrTION MARK nNF DFM nNLY IN BOXES A. S. AND C. AND ALL THAT APPLIES IN BOX D AND E III OIDIMf: IMPnRMATInm rin,P A IF ARnVF nRnllNn OR U IF UNDERGROUND. BOTH IF APPUCABLE A. ® 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 5 INTERNAL BLADDER SYSTEM ❑ 95 UNKNOWN A. TYPE OF SYSTEM ❑ 2 SINGLE WALL ❑ 4 SINGLE WALL IN A VAULT ❑ 99 OTHER B. ❑ 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/ FIBERGLASS REINFORCED PLASTIC B. TANK MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ® 8 100% METHANOL COMPATIBLE VWFRP (PN—ryT-k) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER D. ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC UNING C. INTERIOR LINING OR ❑ 5 GLASS LINING 6 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES —At t'NO— D. EXTERIOR ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP © 4 FIBERGLASS REINFORCED PLASTIC CORROSION El5 CATHODIC PROTECTION ❑ 91 NONE ❑95 UNKNOWN ❑ 99 OTHER PROTECTION SPILL CONTAINMENT INSTALLED (YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED (YEAR) VES NO_ E. SPILL AND OVERFILL, BTC. DROP TUBE VES_✓ NO_ STRIKER PLATE YES_ NO DISPENSER CONTAINMENT III OIDIMf: IMPnRMATInm rin,P A IF ARnVF nRnllNn OR U IF UNDERGROUND. BOTH IF APPUCABLE A. SYSTEM TYPE A U 1 SUCTION AIU 2 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLEPIPING A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL A 0 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND CORROSION PROTECTION A U A U A U 1 BARE STEEL 5 ALUMINUM 9 GALVANIZED STEEL A U A U A U 2 STAINLESS STEEL A U 6 CONCRETE A U 10 CATHODIC PROTECTION 3 POLYVINYL CHLORIDE (PVC)A U 4 FIBERGLASS PIPE 7 STEEL W/COATNG A G 8 100% METHANOL COMPATIBLE W/FRP A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION ® 1 #ECXO#IGL ME IFAK uTEmoR ❑ 2 LINE IM16Nf$$ 3 CONRNUOxS N(IEB511IIAL d EIFCIRd11C LINE IEsnxO ® MwxTamHO ❑ IFA# oElECTOR 5 AUI0MMIIC MW 99 OTHER muT00WN ❑ V TANK I FAK nETFCTION j 1 VISUAL CHECK ❑ 2 MANUALIUATONORY ❑ 3 VADOZE LZ 4 TIC TANK ❑ 5 GROUNDMONTORINGTER ❑ 6 TESTINGTANK CONINTERSTITIAL RECONC7 ING ❑ 9 SIR E]8 WEEKLY❑ 10 GAUGING MONTHLY TANK ❑ 95 UNKNOWN ❑ 99 OTHER MON INUOU ORIN KGAUGING VI. TANK CLOSURE INFORMATION (PERMANENT CLOSURE IN -PUCE) 1. ESTIMATED DATE LAST USED (MO/DAWVR) 2. ESTIMATED QUANTITY OF 3.WASTANKRLLEDWITH YES ❑ NO❑ 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 D/rA�TCE �/ O (PRWTED A SIGNAL REI Q Il!? } L�Ii-� X p / I.�/r [✓( L' V J / 7 / LOCAL AGENCY USE STATE I.D.# PERMIT NUMBER THE STATE I.D. NISMBERIS COMPOSED OF THE FOUR NUMBERS BELOW COUmNTY # JURISDICTION # FACILITY # TANK # IJ 0_3 1 FTTI '> !.) _. PERMIT APPROVED BYIDATE PERMIT THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPN - FORM A, UNLESS A CURRENT FORMA HAS BEEN FILED. 5gWC MUST BE COMPLETED FOR INSTALLATIONS. THIS FORM SHOULD BE ACCOMPANIED BY A PLOT OW FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING TH RGROUND STORAGE TANK REGULATIONS FORM B (6-95)