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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 ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSON SITE ONE REM ❑ 2 INTERIM PERMIT F-14 AMENDED PERMIT E:]8 TEMPORARY TANK CLOSURE E]8 TANK REMOVED a DBA OR FACILITY NAME WHERE TANK IS INSTALLED: Som �✓ Lo O Y Av `�,�J c113o I T'AKIV nC0P010TIn K1 -_.._.___ A OWNER'S TANK I. D. # o/ B. MANUFACTURED BY: C/- 4 C. DATE INSTALLED (MO/DAYNEAR) G3 % D. TANK CAPACITY IN GALLONS: / Z uLD II. TANK CONTENTS IFA -1 IS MARKED, COMPLETE ITEM C. A 1 MOTOR VEHICLE FUEL ❑ 4 OILB. ❑T�� 1 DOUBLE WALL C, M_la REGULAR UNLEADED ❑ 3 DIESEL ❑ 8 AVIATION GAS ❑ 2 PETROLEUM ❑ 80 EMPTY 1 PRODUCT F-14 SINGLE WALL IN A VAULT 1b PSE MIUM UNLEADED ❑ 4 GASAHOL ❑ 7 METHANOL B. TANK E2` 1 BARE STEEL ❑ 2 STAINLESS STEEL 1:11C MIDGRADE UNLEADED ❑ 5 JETFUEL E:]8 MBS E:]3 CHEMICALPRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 5 CONCRETE ❑ 2 LEADED ❑ 99 OTHER(OESCRIBE IN ITEM D. BELOW) 0. IF (A.1) 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 ❑T�� 1 DOUBLE WALL F-13 SINGLE WALL WITH EXTERIOR LINER [:]5 INTERNAL BLADDER SYSTEM ❑ 95 UNKNOWN SYSTEM n 2 SINGLE WALL F-14 SINGLE WALL IN A VAULT ❑ 99 OTHER B. TANK E2` 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W1 FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 8 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER C. INTERIOR ❑ 1 RUBBER LINED��❑II 2 ALKYD LINING F--]3 EPDXY LINING ❑ 4 PHENOLIC LINING LINING OR F-15 GLASS LINING 8 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 1001/6 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 '—OVERFILL ❑ 99 OTHER E. SPILL AND OVERFILL, etc. SPILL CONTAINMENT INSTALLED (YEAR) 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 1 SUCTION AS) 2 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION A S?1 SINGLE WALL A U 2 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 1 BARE STEEL 5 ALUMINUM 9 GALVANIZED STEEL A U 2 STAINLESS STEEL A U A U B CONCRETE A U A U 10 CATHODIC PROTECTION 3 POLYVINYL CHLORIDE (PVC)A U 4 FIBERGLASS PIPE 7 STEEL W/COATING A U 8 100% METHANOL COMPATIBLE W/FRP A/tr�05 UNKNOWN A U 99 OTHER D. LEAK DETECTION [�] 1 MECNANCAL UNE IEAK [:]2 DETECTOR UNE TGWNESS E:]3 mffn CUs INTERSTITIAL ❑ 4 ELAMMIC UNE TESTING MONITORING 1:1 DETECTOR ❑ 5 AWOMATC PUMP —] 99 OTMER SHUTDOWN V. TANK LEAK DETECTION ❑ 1 VISUAL CHECK LJ' MANUAL INVENTORY F-13 VADOZE MONITORING E:]4 GAUGING MONITORING TANK ❑ S GROUND MONTORINGTER ❑ TANK B TESTING ❑ 7 MONITORING INTERSTITIAL ❑ 8 SIR ❑ 9 TANK GAUGINGAL ❑ 10 MOSTINGHLY TANK E:]95 UNKNOWN E]99 OTHER TE 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 E] 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 6 SIGNATURE) LOCAL AGENCY USE ONLY THE STATE I.D. NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY # JURISDICTION # FACILITY # TANK # STATE I.D.# �� ^ r I� I -I 5 6I I I I Ilo It PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION -FORMA, UNLESS A CURRENT FORMA HAS BEEN FILED. FORM C MUST BE COMPLETED FOR INSTALLATIONS. THIS FORM SHOULD BE ACCOMPANIED BY A PLOT PLO LE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE vGROUND STORAGE TANK REGULATIONS FORMS (E95) FOROONBRT