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• • B. STATE OF CALIFORNIA °�, STATE WATER RESOURCES CONTROL BOARD e UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B ��I =� ❑ 3 CHEMICALPRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 STAINLESS STEEL If—Q'I\ UNLEADED ❑ 5 JET FUEL ❑ 8 MBS 2 LEADEMIDGRAD ❑ 2 LEADED ❑ 99 OTHER (DESCRIBE IN REM D. BELOW) COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MATERIAL MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ON SITZ ONE REM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED n DBA OR FACILITY NAME WHERE TANK IS INSTALLED: �j pp 4cW1 74✓!!� �T— I. TANK DESCRIPTION COMPLETE ALL ITEMS— SPECIFY IF UNKNOWN A OWNER'S TANK 1. 0. B. MANUFACTURED BY: C. DATE INSTALLED (MO/DAY/YEAR) Oi D. TANK CAPACITY IN GALLONS: /2 DDD II. TANK CONTENTS IF A-1 IS MARKED, COMPLETE ITEM C. A :Gl_MOTOR VEHICLE FUEL ❑ 4 OIL B. C, ❑ la REGULAR UNLEADED ❑ 3 DIESEL ❑ S AVIATION GAS ❑ 2 PETROLEUM ❑ 80 EMPTY PRODUCT ❑ 4 SINGLE WALL IN A VAULT O lb PREMIUM UNLEADED ❑ 4 GASAHOL ❑ 7 METHANOL ❑ 3 CHEMICALPRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 STAINLESS STEEL If—Q'I\ UNLEADED ❑ 5 JET FUEL ❑ 8 MBS 2 LEADEMIDGRAD ❑ 2 LEADED ❑ 99 OTHER (DESCRIBE IN REM D. BELOW) D. IF (A.1) 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 OFDOUBLE 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 ❑ 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS p❑ ( 7N 4 STEEL CLAD Wl FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑—' B 100% METHANOL COMPATIBLE W/FRP (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER C. INTERIOR ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 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 F—]1 POLYETHYLENE WRAP E:]2 COATING ❑ 3 VINYL WRAP ,,p.., I"Q' 4 FIBERGLASS REINFORCED PLASTIC CORROSION PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE E] 95 UNKNOWN `y ❑ 99 OTHER E. SPILL AND OVERFILL,eTC. SPILL CONTAINMENT INSTALLED (YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED (YEAR) DROP TUBE YES NO STRIKER PLATE VES NO_ DISPENSER CONTAINMENT YES NO IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND 08 U IF UNDERGROUND, BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION A(g;? PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL A 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 STEEL W/COATING A U 100% METHAN0j. COMPATIBLE W/FRP A U 95 UNKNOWN �g OTHER II6!Q�• •e—' D. LEAK DETECTION❑ ❑ 1 MECNNIICAL UNE UE DETECmR ❑ 2 MUNE T NEM COIMNUWS NTERSTIM 4 ELECTRONIC LME 5 AUTOMATIC PUMP TESTING ONTCRING ❑ IM GETECMR ❑ SHUTDOWN 99 OTHER V. TANK LEAK DETECTION 1 VISUAL CHECK ❑ 2 MANUAL RECONCILIATION MONITORING [:]3 MONIITORING OZE E:]4 AUTOMATIGAUGING MONITORING TANK ❑ 5 GROUND MONTORINGTER F7 ANNUALTANK 8 TESTING MON TOR NUG INTERSTITIAL ❑ S SIR ❑ 9 WEEKLY MANUAL ❑ 10 MONTHLY TANK E::]95 UNKNOWN ❑ 99 OTHER TANK GAUGING TESTING VI. TANK CLOSURE INFORMATION (PERMANENT CLOSURE IN-PIACE) 1. ESTIMATED DATE LAST USED (MODAYNR) 2. ESTIMATED QUANTITY OF 3. WAS TANK FILLED WITH YES ED NO ❑ SUBSTANCE REMAINING GALLONS IN 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 DATE (PRINTED b SIGNATURE] LOCAL AGENCY USE ONLY THE STATE I.D. NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY # JURISDICTION # FACILITY # TANK # STATE I.D:# m= M3E/c, PERMIT NUMBER PERMIT APPROVED BYIDATE PERMIT EXPIRATION DATE THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPU ON -FORM A, UNLESS A CURRENT FORM A HAS BEEN FILED. FO C MUST BE COMPLETED FOR INSTALLATIONS. THIS FORM SHOULD BE ACCOMPANIED BY A PLOT PILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THFWRGROUND STORAGE TANK REGULATIONS FORM B (6.95)