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• • MANUFACTURED BY: /cl C. DATE INSTALLED (MO/DAYNEAR) £� pY D. TANK CAPACITY IN GALLONS' 16 STATE OF CALIFORNIA ��T Ne1 PRODUCT STATE WATER RESOURCES CONTROL BOARDUNDERGROUND 1 GASAHOL ❑ 7 METHANOL ❑ 5 JETFUEL ❑ 8 M85 STORAGE TANK PERMIT APPLICATION - FORM B a ❑ 2 LEADED ❑ 99 OTHER (DESCRIBE IN REM D. BELOM 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 SITE ONE REM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: 7,3vpGy4/ /9ylE I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A OWNER'S TANK I. D. #B. MANUFACTURED BY: /cl C. DATE INSTALLED (MO/DAYNEAR) £� pY D. TANK CAPACITY IN GALLONS' 16 II. TANK CONTENTS IF A-1 IS MARKED, COMPLETE ITEM C. p 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C. ❑ to REGULAR UNLEADED 3 DIESEL ❑ 6 AVIATION GAS 2 PETROLEUM ❑ 80 EMPTY ��T Ne1 PRODUCT ❑ ib PREMIUM UNLEADED ❑ 1C MIDGRADE UNLEADED 1 GASAHOL ❑ 7 METHANOL ❑ 5 JETFUEL ❑ 8 M85 ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN 2 WASTE ❑ 2 LEADED ❑ 99 OTHER (DESCRIBE IN REM D. BELOM D. IF (Al) 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 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 8 100% METHANOL COMPATIBLE W/FRP (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER C. INTERIOR ❑ I RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING LINING OR ❑ 5 GLASS LINING ❑ 8 UNLINED f!!J.95 UNKNOWN ❑ 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 1006 METHANOL? YES— NO— D. EXTERIOR ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC CORROSION PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE 5 UNKNOWN ❑ 99 OTHER E. SPILL AND OVERFILL, BLC. SPILL CONTAINMENT INSTALLED (YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED (YEAR) DROPTUBE 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 1 SUCTION A 2 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL Aa,—'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 I 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 U S 100% METHAVL COMPATIBLE W/FRP A U 95 UNKNOWN Aar"Er9 OTHER AtM4_ D. LEAK DETECTION1 MECHANICAL UNE LEAK ❑ DETECTOR ❑ 2 UNE TG ESS 3 CONTINUOUS INrinr[PAL 4 ELIM DEMMC ONE 5 AVOW= RIM? O TESTING IXATORPIG ❑ L=R ❑ SMRDOWN 99 OTHER V. TANK LEAK DETECTION /y,❑- L 1 VISUAL CHECK ED RECONCILANUAL IATIONORY ❑ 3 MONIITORING VAOZE ❑ k 4 GAUGING AUTOMATIC TANK ❑ 5 MONITORINGROUND G ❑ e TTEESTINGANNUALTAN '�\ MONITORING INTERSTITIAL❑ 8 SIR ❑ 9 TANK GLY ❑ 10 MOSTINGHLY TANK ❑ 95 UNKNOWN ❑ 99 OTHER TE VI. TANK CLOSURE INFORMATION (PERMANENT CLOSURE IN-PLACE) 1. ESTIMATED DATE LAST USED (MO/DAWYR) 2. ESTIMATED QUANTITY OF 3. WAS TANK FILLED WITH YES [:D NO ❑ SUBSTANCE REMAINING GALLONS INERT 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 8 SIGIUTUAE) LOCAL AGENCY USE ONLY THE STATE I.D. NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY # JURISDICTION # FACILITY # j TANK # �Q STATE I.D:# m p 7/�3 PERMIT NUMBER PERMIT APPROVED BYIDATE PERMIT EXPIRATION DATE ^ r^ THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION - FORM A, UNLESS A CURRENT FORMA HAS BEEN FILED. FORM C MUST BE COMPLETED FOR INSTALLATIONS. THIS FORM SHOULD BE ACCOMPANIED BY A PLOT PWLE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING TH JWRGROUND STORAGE TANK REGULATIONS FORM B (6.95)