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STATE OF CALIFORNIA �0+. STATE WATER RESOURCES CONTROL BOARD +,,,�I " -. e 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 ONIT ONE REM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED 1 �/ DBA OR FACILITY NAME WHERE TANK IS INSTALLED: ❑ 4 SINGLE WALL IN A VAULT to A✓1` B. 'A IV ne CPO1GTInM AL I TCAAS_ GPFCIFY IF UNKNOWN A OWNER'S TANK I D # B. MANUFACTURED BY: v �/ C DATE INSTALLED(MO/DAYNEAR) 1171 D. TANK CAPACITY IN GALLONS: Z �� II TA IV PAWITCAITC eP¢cn nnAAPI PTF ITEM C. �1 MOTOR VEHICLE FUEL ❑ 4 OIL B. T{�j � C. 1E REGULAR UNLEADED ❑ 3 DIESEL ❑ 8 AVIATION GAS A. ❑ 2 PETROLEUM ❑ 80 EMPTY lT PRODUCT ❑ G PREMIUM UNLEADED ❑ 4 GASAHOL ❑ ]METHANOL ❑ Ic MIDGRADE UNLEADED ❑ 5 JETFUEL ❑ 8 M85 ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED ❑ 99 OTHER (DESCRIBE IN ITEM D. BELOY!) 0. IF (A1) IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C. A. S. M: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.3,AND C, AND ALL THAT APPLIES IN BOX D AND rlrmry UNrvnrvin nvl. �In�.c .. ,�...................__.. _ .. _.--- - 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 5 INTERNAL BLADDER SYSTEM F]95 UNKNOWN A. TYPE OF❑I�4 SYSTEM 5 –2 SINGLE WALL ❑ 4 SINGLE WALL IN A VAULT ❑ 99 OTHER B. M'l BARE STEEL ❑ 2 STAINLESS STEEL ❑. 3 FIBERGLASS ❑ 4 STEEL CLAD W/ FIBERGLASS REINFORCED PLASTIC B. TANK 5 CONCRETE ED 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP MATERIAL (PTI=D'T>MK) ❑ ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER 3 POLYVINYL CHLORIDE (PVC)A U 4 FIBERGLASS PIPE 7 STEELW/COATING A U 9 100% METHANOL COMPATIBLEW/FRP AV95 UNKNOWN A U 99 OTHER ❑ 1 RUBBER UNED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING C. INTERIOR LINING OR ❑ 5 GLASS UNING �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 CORROSIONg1 ❑ 5 CATHODIC PRoTEcnON NONE 95 UNKNOWN ❑ ❑ 99 OTHER PROTECTION N SPILL 1:11:115:INS TALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(NEAR) NO E. SPILL AND OVERFILL, BTO. DROP TUBE YES NO STRIKER PLATE YES_ NO DISPENSER CONTAINMENT YES_ ... _._..._ ...__..u.„�u _ ___ .. ............ a mlun R1M IF APPI ICARL5 IV. rlrmry UNrvnrvin nvl. �In�.c .. ,�...................__.. _ .. _.--- - A. SYSTEM TYPE A U 1 SUCTION A4 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION IV, SINGLE WALL A U 2- DOUBLE WALL A U 3 UNED 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 2 STAINLESS STEEL A U A U 6 CONCRETE A U A U 10 CATHODIC PROTECTION 3 POLYVINYL CHLORIDE (PVC)A U 4 FIBERGLASS PIPE 7 STEELW/COATING A U 9 100% METHANOL COMPATIBLEW/FRP AV95 UNKNOWN A U 99 OTHER D. LEAK DETECTION ❑ 1 MECNM&CM. UNE IFAK DETECTOR ❑ 2 UNE PGNTNE55 ❑ 3 CON9NUW3 NRER.111. ❑ 4 RECFiCMC UNE ❑ TEsnNG MONITORING LEAK DETECTOR 5 AUfOMAIIG PUMP ❑ 99 OTHER SNUTGOWN e.IV IeAV nCTCrTlnnl I. Innn ��n1. ..•�• •. GROUND FD 1 VISUAL CHECK LJ 2 RANUAL ECONCILIATIONORY ❑ 3 MONIITORING ❑ 4 GAUGING MONITORING TANK F-15 MONTORINGTER ❑ 8 TETANN VAOZESTING E] 7 MON INUO G INTERSTITIAL ❑ 8 SIR ❑ 9 WEEKLY 99 OTHER NK GAUGING ❑ 10 MONTHLTESTING TANK ❑ 95 UNKNOWN ❑ VI. TANK CLOSURE INFORMATION (PERMANENT CLOSURE IN-PLACE) 1. ESnMATED DATE LAST USED (MO/DAYNA) 2. ESTIMATED QUANTITY OF 3. WAS TANK FILLED WITH YES ❑ NO ❑ SUBSTANCE REMAINING GALLONS INERTMATERIAL? .,.r„1o1c11CAAVVAlnuncnrF LS TRUFAND CORRECT THA rVfm MAO CICCIV I.VrvIrLc•�✓�,�✓u, •_...._.. �. _..__..... DATE TANK OWNER'S NAME (PRINTED& SIGNATURE) .00AL AGENCY USE ONLY THE STATE I.D. NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY # JURISDICTION # FACILITY # TANK # STATE I.D.# I 1 11 Is I I I I �o N ///;;46 'ERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE uIG Cl1F THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION - FORMA, UNLESS A GUHKLN I rUHM A nAa PLFN rl.u.. r..•.,..,.,�-.---T,..._-.--._.•��--..---I��-�--- SHOULDBEACCOMPANIEDBYAPLOTPVETHISFORMWITHTHELOCALAGENCYIMPLEMENTINGTHE GROUND STORAGE TANK REGULATIONS FORR03/6R] FORM B (6-95)