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0 0 STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B 1 COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ONSITE ONE REM Q 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE Q 8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: B. TANK MATERIAL Q 5 CONCRETE Q 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 6 100% METHANOL COMPATIBLE W/FRP I TANK nFRrRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A. OWNER'S TANK I. D.0 B. MANUFACTURED BY: C DATE INSTALLED (MC/DAYNEAR) ^. / D. TANK CAPACITY IN GALLONS TAUV nnAITO\ITC o U—cTCITCUI ..A. ...--...-..._ _. _ ❑. 1 MOTOR VEHICLE FUEL d OIL B. C. ❑ to REGULAR UNLEADED ❑ 3 DIESEL Q 6 AVIATION GAS ❑ Ib PREMIUM UNLEADED ❑ 4 GASAHOL Q 7 METHANOL Q 2 PETROLEUM ❑ 80 EMPTY E:l 1 PRODUCT Q lc MIDGRADE UNLEADED Q 5 JET FUEL ❑ 8 M85 Q 3 CHEMICALPRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED Q 99 OTHER (DESCRIBE IN ITEM D. BELOW) D. IF (A.1) IS NOT MARKED. ENTER NAME OF SUBSTANCE STORED C. A. S. #: 111 TAAIM' /`nMCTCIICTIr)KI ""eov nuc lTPM nNI V IN FOXES A.B.ANDC. AND ALLTHATAPPLIES INBOX DANDE n"".1^1kI i•. no U m uuncononuun RnTH IF APP? ICABLE r�., a u.... u .. ... ........ ❑—I I DOUBLE WALL Q 3 SINGLE WALL WITH EXTERIOR LINER Q 5 INTERNAL BLADDER SYSTEM Q 95 UNKNOWN A. TYPE OF SYSTEMII--JJcc--II 2 SINGLE WALL ❑ 4 SINGLE WALL IN A VAULT Q 99 OTHER A U L I BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS Q 4 STEEL CLAD W/ FIBERGLASS REINFORCED PLASTIC B. TANK MATERIAL Q 5 CONCRETE Q 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 6 100% METHANOL COMPATIBLE W/FRP (Primary Tank) ❑ 9 BRONZE Q 10 GALVANIZED STEEL ❑ 95 UNKNOWN Q 99 OTHER 1 BARE STEEL 5 ALUMINUM 9 GALVANIZED STEEL ❑ I RUBBER LINED Q 2 ALKYD LINING ❑ 3 EPDXY UNING Q 4 PHENOLIC LINING C. INTERIOR LINING OR ❑ 5 GLASS LINING Q 6 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES— NO— D. EXTERIOR ❑ 1 POLYETHYLENE WRAP Q 2 COATING Q 3 VINYL WRAP Q 4 FIBERGLASS REINFORCED PLASTIC CORROSION91 ❑ 5 CATHODIC PROTECTION El NONE 0 95 UNKNOWN ❑ 99 OTHER PROTECTION SPILL CONTAINMENT INSTALLED (YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED (YEAR) E. SPILL AND OVERFILL, 81C. DROP TUBE YES _ NO _ STRIKER PLATE YES_ NO _ DISPENSER CONTAINMENT YES _ NO n"".1^1kI i•. no U m uuncononuun RnTH IF APP? ICABLE r�., a u.... u .. ... ........ _.. _...-__ .. .. .. _._ - A. SYSTEM TYPE A U 1 SUCTION A U- 2 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION A U.'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 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 B 100% METHANOL COMPATIBLE W/FRP A, -U_• 95 UNKNOWN A U 99 OTHER— D. LEAK DETECTION D. ❑ MECHANIGI UNEL X DETECTOR ❑ 2 LINE TImRNE55 3 CON9NU NG INTERSTITIAL ❑ 4 ELECTFORIC UNE ❑ TESTING ❑ MONRORING LEAK DETECTOR 5 AmO1MTIC PUMP ❑ 99 OTHER SHUTDDM I TAAIV I GAT[ PIGTPrTInM •❑'1 VISUAL CHECK El RECONCILIATION RMANUAL ECONCILI TIIONORY E]3 VAEMONITORING ❑ 4 GAUGING MONITORING TANK ❑ 5 MONITORINGTER Q e TETANK STING ❑ 7 MONTOR NG INTERSTITIAL ❑ 8 SIR ❑ 9 TANK WEEKLY MANUAL Q 10 MONT HLY TANK ❑ 95 UNKNOWN Q 99 OTHER TrSNG VI. TANK CLOSURE INFORMATION (PERMANENT CLOSURE IN-PLACE) 1. ESTIMATED DATE LAST USED (MO/DAY/YR) 2. ESTIMATED QUANTITY OF 3. WAS TANK FILLED WITH YES ❑ NO ❑ SUBSTANCE REMAINING GALLONS INERT MATERIAL? THI,' r Mn== PFAIA/ TY nF PFR.IURY 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 # �FACILIT�-Y- #� TANK � STATE I.D.# m PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION- FORM A, UNLESS A CURRENT FORMA HAS BEEN HLI,U. runm u Mw Pc wmrw cu rv�,.�n.�..••....,. SHOULD BE ACCOMPANIED BY A PLOT PLOE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE *GROUND STORAGE TANK REGULATIONS FORDOS<6R7 FORM B (6-95)