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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 CLOSED ON SITE ONE REM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED C.. 7 DBA OR FACILITY NAME WHERE TANK IS INSTALLED: o7-4-0- - �l D I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A OWNER'S TANK I. D. # ? B. MANUFACTURED BY: C. DATE INSTALLED(MO/DAYNEAR) / rj` 7 D. TANK CAPACITY IN GALLONS: IL TANK CONTENTS IFA -1 IS MARKED, COMPLETE ITEM C. p �1 MOTOR VEHICLE FUEL 040IL B. C, 1a REGULAR UNLEADED ❑ 3 DIESEL ❑ 8 AVIATION GAS ❑ 2 PETROLEUM ❑ 80 EMPTY IIII�--------',,,,�ppppT �1 PRODUCT ❑ 1b PREMIUM UNLEADED ❑ 4 GASAHOL ❑ 7 METHANOL ❑ 3 CHEMICALPRODUCT ❑ 85 UNKNOWN ❑ 2 WASTE ❑ 1c MIDGRADE UNLEADED ❑ 2 LEADED ❑ 5 JET FUEL ❑ 8 M85 ❑ 99 OTHER (DESCRIBE IN REM D. BELOM 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 n ANI) F A. TYPE OF 1 DOUBLE WALL [:]3 SINGLE WALL WITH EXTERIOR LINER ❑ 5 INTERNAL BLADDER SYSTEM F-195 UNKNOWN SYSTEM �❑�qq [a 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 WIFRP (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 F(5q 6 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 100°/. METHANOL7 YES_ NO— D. EXTERIOR CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE F27195 UNKNOWN ❑ 99 OTHER E. SPILL AND OVERFILL, BIC. SPILL CONTAINMENT INSTALLED (YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED (YEAR) DROPTUBE VES_ NO_ STRIKERPLATE 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 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 S 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 ALV95 UNKNOWN A U 99 OTHER D. LEAK DETECTION ❑ 1 MEcWV KAL UNE LEAK ❑ GETECTOA 2 UNE TIGHTNESS ❑CM 3 CINUWS W MTmAL 4 ELEM MC LINE TEGTWG MGMTIXVMO ❑ LEAN DETECTOR 5 AUTCM4TIC PUMP vUTX)wN ❑ 99 OTHER V, TANK LEAK DETECTION ❑ 1 VISUAL CHECK L{G 2 RECONCILATIONINVENTORY ❑ 3 VADOZE MONITORING ❑ 4 GAUGWGAUTOMATIC TANK ❑ 5 GROUND MON TORINGWATER ❑ 6 ANNUALTANK ❑ 7 MONITORING INTERSTTIAL PiL--JI 8 SIR ❑ 9 WEEKLY MANUAL ❑ 10 MONTHLY TANK ❑ 95 UNKNOWN E:]99 OTHER TANK GAUGING TESTING VI. IANK L:LUSUHE INFORMATION (PERMANENT CLOSURE IN-PLACE) 1, ESTIMATED DATE LAST USED (MO/DAYNR) 2. ESTIMATED QUANTITY OF 3. WAS TANK FILLED WITH YES ❑ 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 A SIGNATURE) LOCAL AGENCY USE ONLY THE STATE I.D. NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW STATE I.D:# COUNTY # JURISDICTION # FACILITY # TANK # - PERMIT NUMBER PERMIT APPROVED BVA)ATE PERMIT EXPIRATION DATE I nl5 FUHM MUST BE ACCOMPANIED BY A PERMIT APPLICATION- FORM A, UNLESS A CURRENT FORM A HAS BEEN FILED. FORM C MUST BE COMPLETED FOR INSTALLATIONS. THIS Fn - SHOULD BE ACCOMPANIED BY A PLOT PULE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE wGROUND STORAGE TANK REGULATIONS FORM B (6.95) - FOR00