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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 O 3 RENEWAL PERMIT O 5 CHANGE OF INFORMATION O 7 PERMANENTLY CLOSED ON SITE ONE ITEM ❑ 2 INTERIM PERMIT O 4 AMENDED PERMIT O 6 TEMPORARY TANK CLOSURE O B TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: /00 `- 20 A ve, lj0 I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A OWNER'S TANK I.D.Y .�, B. MANUFACTURED BY: v C. DATE INSTALLED(MO/DAYNEAR) - D. TANK CAPACITY IN GALLONS: II.TANK CONTENTS IFA-1 IS MARKED,COMPLETE ITEM C. A 1 MOTOR VEHICLE FUEL O 4 OIL B. C. 1a REGULAR UNLEADED O 3 DIESEL E:] 6 AVIATION GAS O\'2 PETROLEUM ❑ 80 EMPTY 1 PRODUCT 1b PREMIUM UNLEADED O 4 GASAHOL ❑ T METHANOL O 1c MDGRADE UNLEADED ❑ 5 JET FUEL O 8 MBS O 3 CHEMICALPRODUCT ❑ 95 UNKNOWN 2 WASTE O 2 LEADED O 99 OTHER(DESCRIBE IN ITEM D.BELOW) D. IF(A.1)IS NOT MARKED. ENTER NAME OF SUBSTANCE STORED C.A.S.N: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.8,AND C.AND ALL THAT APPLIES IN BOX D AND E A. TYPE OF ❑ 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 ❑ I BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE O 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ B 100% METHANOL COMPATIBLE WIFRP (Primary Tank) ❑ 9 BRONZE O 10 GALVANIZED STEEL 95 UNKNOWN ❑ 99 OTHER C.INTERIOR ❑ 1 RUBBER LINED O 2 ALKYD LINING 3 EPDXY LINING ❑ 4 PHENOLIC LINING LINING OR ❑ 5 GLASS LINING ❑ 6 UNLINED85 UNKNOWN O 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? ES— NO— D'EXTERIOR O 1 POLYETHYLENE WRAP O 2 COATING O 3 VINYL WRAP O 4 FIBERGLASS REINFORCED PLASTIC CORROSION PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE UNKNOWN O 99 OTHER E.SPILL AND OVERFILL,BLD. SPILL CONTAINMENT INSTALLED(YEAR) VERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) DROP TUBE YES_ 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 / 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 U 2.DOUBLE WALL A U 3 LINED TRENCH AM 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)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 WIFRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A6�5 UNKNOWN A U 99 OTHER D. LEAK DETECTION1 NECHAN1 A UNE U10M 2 IME TIGKINE55 3 CONTINUOUS INTERSTInRL 4 EIECTRDMC LINE 5 AUfDIMiID W1P ❑ [(1ECIDR ❑ TESTING ❑ MONITOHING ❑ lEAR LEIECTOR ❑ SH=I C ❑ 99 OTHER V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 MANUAL RECONCILIATION MONITORING E:] 3 MON ORING OZE O 4 AUTOMATGAUGING IC TANK [—] TANK 5 GROUND MONITORING TER ❑6 ANNUALTESTING ❑ 7 CONTINUMONITORU INTERSTITIAL ❑ 8 SIR ❑ 9 WENKGAUGANUAL ❑10 MOTINGY TANK lq 5 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) 1.ESTIMATED DATE LAS T US D M A R) 2 ESTIMATED QUANTITY TANK FILLED SUBSTANCE REMAININGF GALLONS 3 W�INERT MATERIAL 7H YES Q NO❑ 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 SIGNATURE) LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY M JURISDICTION N FACILITY N TANK k STATE I.D:# O 0 0 X6/6 9 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 INSTALLATIONS.THIS FORM SHOULD BE ACCOMPANIED BY A PLOT PLA' 'LE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE LI TGROUND STORAGE TANK REGULATIONS FORM B (6-95) \w %of