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• STATE OF CALIFORNIA • ^`�W �..'cy STATE WATER RESOURCES CONTROL BOARD "� o UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B "� LL =_ COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ON SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: ZSw cyi, GOQ7 w� MATERIAL Gj' 30�9b TAMIL nccroHnTlnu ...... ,_... .--..- ---_....-_____._. ❑ 8 100% METHANOL COMPATIBLE W/FRP (Primary Tank) ❑ 9 BRONZE A OWNER'S TANK I.D.# Z_ B. MANUFACTURED BY: tj..N C. DATE INSTALLED(MO/DAYNEAR) o�.f- * D. TANK CAPACITY IN GALLONS: / Z�&VV II. TANK CONTENTS IFA -11S MARKED, COMPLETE ITEM C. A. �1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C. ® 1a REGULAR UNLEADED ❑ 3 DIESEL ❑ 6 AVIATION GAS ❑ 2 PETROLEUM ❑ 80 EMPTY El 1 PRODUCT ❑ 4 SINGLE WALL IN A VAULT Ellb PREMIUM UNLEADED ❑ 4 GASAHOL ❑ 7 METHANOL E:] 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 STAINLESS STEEL E::]1C MIDGRADE UNLEADED ❑ 5 JET FUEL ❑ 8 M85 ❑ 2 LEADED ❑ 99 OTHER (DESCRIBE IN ITEM D. BELOW) D. IF (Al) IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C. A S. #: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES &B.AND C. AND ALL THAT APPLIES IN BOX D AND A. TYPE OFI-T❑ 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER E]5 INTERNAL BLADDER SYSTEM ❑ 95 UNKNOWN SYSTEM 2 SINGLE WALL ❑ 4 SINGLE WALL IN A VAULT ❑ 99 OTHER B. TANK II-(�w N 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 ❑ 1 RUBBER UNED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING LINING OR ❑ 5 GLASS LINING Ell UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 100% 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 ❑ 99 OTHER E. SPILL AND OVERFILL, BLL. SPILL CONTAINMENT INSTALLED DROP TUBE (YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED (YEAR) YES_ NO_ STRIKER PLATE YES NO_ DISPENSER CONTAINMENT YES_ NO IV. YIF'INO INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND, BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION A n PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION A 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 6 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(P5 UNKNOWN A U 99 OTHER D. LEAK DETECTIONI MEC IM UNE UE ❑ D uon ❑ 2 UNE W 3 COMNU S Im TmAI 4 ELECIRCNIC UNE TESTING TMHR ❑ AK)NTORNG ❑ LEAK OEIECTOR 5 AaOWTIC WAIF MVTIX)m ❑ 99 OTHER V. TANK LEAK DETECTION ❑ 1 VISUAL CHECK 2 INVENTORY r7 3 ❑4 C TANK TER ❑ S ANNUAL TANK �RECONCILIATION MONITORING GAUGING MONITORING TESTING E:] IN�B SIR 9 pEKGMON TOR NG AUG ❑ 10 MOSTINGHLY TANK ❑ 95 UNKNOWN E::]99 OTHER TE VI. IANK CLOSURE INFORMATION (PERMANENT CLOSURE IN-PLACE) 1. ESTIMATED DATE LAST USED (MO/DAY/YR) 2. ESTIMATED QUANTITY OF 3. WAS TANK FILLED WITH SUBSTANCE REMAINING GALLONS INERT MATERIAL? YES ❑ NO ❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY. AND TO THE BEST OF MY KNOWLFOAF I.4 TRI IF ANn rnaacrr TANK OWNER'S NAME DATE (PRINTED d SIGNATURE) LOCAL AGENCY USE ONLY THE STATE I.D. NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY # JURISDICTION # FACILITY # TANK # STATE I.D.# [�B] = Ia 3 S ®9 PERMIT NUMBER PERMIT APPROVED BYIDATE PERMIT EXPIRATION DATE I nla rVI4M 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 (6-95) SHOULD BE ACCOMPANIED BY A PLOT PILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE wGROUND STORAGE TANK REGULATIONS FOR