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0 STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. _� C./?� 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 ❑ 6 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: S4�fC �'GIsPpEA: t`i .�tl Iy,2 LO Ki 7^�,; %�„f LG {�i L/ l.0. I TANK OFSCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A OWNER'S TANK 1. D. B. URED BY: /19Ud ,x 4 f _ , C. DATE INSTALLED (MO/DAYNEAR) D G i S 'l X D. TANK CAPACITY IN GALLONS: ZY UTl C' II TAMK CnNTFNTC m A_I is uaR¢cn nnuPI FTF ITEM C. A O 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C. ❑ 1a REGULAR UNLEADED 0] 3 DIESEL ❑ 6 AVIATION GAS ❑ 1M PREMIUM UNLEADED ❑ 4 GASAHOL ❑ 7 METHANOL ❑ 2 PETROLEUM ❑ 80 EMPTY ® / PRODUCT tc MIDGRAOE UNLEADED ❑ 5 JET FUEL ❑ 8 M85 ❑ 3 CHEMICALPRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED ❑ 99 OTHER (DESCRIBE IN ITEM D. BELOM D. IF (A1) 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 III DID1Mr INFnRWATInM rlDric A ICARnvcr.RnuunnR U IFUNDERGROUND. BOTH IFAPPUCASLE A. ® 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR UNER ❑ 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 © 6 100% METHANOL COMPATIBLE NFRP (PHRMry Tank) ❑ 9 BRONZE O 10 GALVANIZED STEEL O 95 UNKNOWN ❑ 99 OTHER D. ❑ 1 RUBBER LINED [:] 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING C. INTERIOR LINING OR ❑ 5 GLASS LINING 0 6 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YESS-Z NO— D. EXTERIOR ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC CORROSION ❑ CATHODIC PROTECTION ❑ 91 NONE ❑95 UNKNOWN ❑ 99 OTHER PROTECTION 5 SPILLCONTAINMENT INSTALLED (YEAR) Il 1 7 OVERFILL P EVENTION EQUIPMENT INSTALLED (YEAR) E. SPILL AND OVERFILL, etc. DROP TUBE YES � NO_ STRIKER PLATE YES NO _ DISPENSER CONTAINMENT YES— NO III DID1Mr INFnRWATInM rlDric A ICARnvcr.RnuunnR U IFUNDERGROUND. BOTH IFAPPUCASLE 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 1 SINGLE WALL A(IU)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/COATING A@8 100% METHANOL COMPATIBLE W/FRP A U 95 UNKNOWN A U 99 OTHER - D. LEAK DETECTION 1 MEGUMLIL UNE LE.11( EE ❑ 2 UNE TIGRINE53 t �I 3 CGNIMMUUS mIFR5TILLL 4 EN:CIRONIC NNE resfa+G ICI MmR mG ❑ IFAN nElEcroR ® 5 Ju fGMABC PUMP yy OTHER sHMToowx ❑ U TANK I FAK DFTFCTION ❑NUAL 1 VISUAL CHECK E]2 MANUAL INVENTORY ❑ 3 VA OLIATION ITORING © 4 GAUG IN C TANK ❑ 5 NITORINGOUNDTER 7-1 6 STINGTANK ❑ 7 MONITORINGINTERSTITIAL ❑ 8 SIR ❑ e WEEKLY MANUAL ❑ 10 MONTHLYTESTING TANK ❑ 95 UNKNOWN ❑ 99 OTHER VI. TANK CLOSURE INFORMATION (PERMANENT CLOSURE IN -PUCE) 1. ESTIMATED DATE LAST USED (MO/DAYNR) 2. ESTIMATED QUANTITY OF 3. WAS TANK FILLED WITH YES ❑ NO ❑ SUBSTANCE REMAINING GALLONS INERT MATERIAL rule Fnoeb ub c oeenl enA4P1 cTFn I /NnFR PFNAI TY OF PERJURY. AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT TANK OWNER'S NAME DATE (PRINTED d SIGNATURE) LOCAL AGENCY USE ONLY THE STATE I.D. NUMBER IS COMPOSED OF THE FOUR NUMBERS BELUW • COUNTY # JURISDICTION # FACILITY # - TANK # I / STATE I.D.# m = 1,11= , PERMIT NUMBER PERMIT APPROVED BYIDATE PERMIT EXPIRATION DATE THIS FORM MUST BE ACCOMPANIED BY A PERMIT APP ON -FORMA, UNLESS A CURRENT FORMA HAS BEEN FILED. C MUST BECOMPLETED FOR INSTALLATIUNS. InlSrunm SHOULD BE ACCOMPANIED BY A PLOT FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING Tlw ERGROUND STORAGE TANK REGULATIONS FORMS (695)