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1vGwr_y Uf�,pVG� �-N • STATE OF CALIFORNIA • a�. +�aa STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION -FORM B COMPLETE A SEPARATE ORM FOR EACH TANK SYSTEM. I - [DBA ;OR;FACILITY NLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT CLOSE EM ❑ 2 INTERIM PERMIT ❑ 5 CHANGE OF INFORMA710N ❑ 7 PERMANENTLY CLOSED ON SITE 6 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED _ NAME WHERE TANK IS INSTALLED: �Zt��OLn - J I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A OWNER'S TANK I.D.# Z B. MANUFACTURED BY: NSTALLED(MO/OAV/YEAR) iV 41� O DATE IU�� ' D. TANK CAPACITY IN GALLONS: cw II.TANK CONTENTS IFA-1 IS MARKED,COMPLETE ITEM C. A ❑ 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C 1B REGULAP UNLEADED ❑ 3 DIESEL ❑ 6 AVIATIONGAS ❑ 2 PETROLEUM ❑ 80 EMPTY ❑ 1PRODUCT ❑ 1b PREMIUM UNLEADED E] 4 GASAHOL ❑ 7 METHANOL ❑ 3 CHEMICAL PRODUCT 95 UNKNOWN ❑ 2 WASTE ❑ 1c MIDGRADE UNLEADED ❑ 5 JET FUEL ❑ 8 M85 ❑ 2 LEADED ❑ 99 OTHER(DESCRIBE IN REM D.BELOW) 0. IF(AA)IS NOT MARKED, ENTER NAME OFSUBSTANCE 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 ❑ 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR UNER ❑ 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 7 ALUMINUM ❑ B 100% METHANOL COMPATIBLE W/FRP "MMM Tmk) ❑ 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 UNING ❑ 6 UNLINED 95 UNKNOWN ❑ 99 OTHER COATING IS LINING 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 ❑ 91 NONE 95 UNKNOWN ❑ 99 OTHER E SPILL AND OVERFILL,BIC. SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) DROP TUBE YES_ NO_ STRIKER PLATE VES_ NO DISPENSER CONTAINMENT VES_ NO IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND,BOTH IF APPUCABLE 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 U 2 DOUBLE WALL A U 3 UNED TRENCH A U 95 UNKNOWN A q)99 OTHER C. MATERIAL AND A U 1 BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A U 4 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL W/COATING A U 8 100% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION pU 5 UNKNOWN A U 99 OTHER 1 MECNM4CAL M(EE]IFA?( 2 UNE TK.M M 3 CCNNUWSNTB5T I 4 ELECTRONIC UNE 5 AMOVARC PUMP D. LEAK DETECTION ❑ DET aW ❑ TEmNG ❑ MDNTCPPlG ❑ IFAIt DEi'cCiOR SNUIWYIN ❑ 99 OTHER V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK L] 2 RECONCILIATION MANUALINVENTORY r7 3 MONIITORING VAOZE ❑ 4 GAUGING MONITORING TANK ❑ 5 MONITORINGR ❑ 8 TESTING ANNUAL TANK ❑ GROUND WATE 7 C=NU IU INTERSTITIAL ❑ 8 SIR ❑ 9 TANK WEEKLY MANUAL ❑ 10 M SNTHLY TANK 95 UNKNOWN ❑ 99 OTHER G TTING VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) 1.ESTIMATED DATE LAST USED(MO/DAYNR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES ❑ 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 OWNER'S NAME DATE (PRINTED 6 SIENATURE) LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY#LI0s TANK# STATE I.Dl m = o o O S o y olligigi PERMIT NUMBER PERMIT APPROVED BV/DATE PERMIT EXPIRATION DATE 'W 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 a FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING TH ERGROUND STORAGE TANK REGULATIONS ^ FORM 8 (6-95) I(I y