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STATE OF CALIFORNIA 0 STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B I COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ONSITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE O 8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: -"5pp 14, GppD,s /i✓r TAMIL I'1CSCGIDTION MMPI PTF AIL ITEMS- SPECIFY IF UNKNOWN A. OWNER'S TANK I. D.4 B. C. 1a REGULAR UNLEADED ❑ 3 DIESEL ❑ 6 AVIATION GAS ❑ 1b PREMIUM UNLEADED ❑ 4 GASAHOL ❑ 7 METHANOL B. MANUFACTURED BY: 4" IC. � PRODUCT C DATE INSTALLED (MO/DAYNEAR) /!y 7 ❑ 2 WASTE D. TANK CAPACITY IN GALLONS: /Z,, az z.? II TANK CONTENTS IFA -11S MARKED COMPLETE ITEM C. •1 MOTOR VEHICLE FUEL ❑ 4 OIL A B. C. 1a REGULAR UNLEADED ❑ 3 DIESEL ❑ 6 AVIATION GAS ❑ 1b PREMIUM UNLEADED ❑ 4 GASAHOL ❑ 7 METHANOL ❑ 2 PETROLEUM ❑ 80 EMPTY � PRODUCT ❑ 1c MIOGRADE UNLEADED ❑ 5 JET FUEL ❑ 8 MBS ❑ 3 CHEMICALPRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED ❑ 99 OTHER (DESCRIBE IN REMD. BELOM7 D. IF (A.1) IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C. A. S. #: v nnAtnTnI In"^Kl v iu enure e P Bunn ANn All THAT APPLIES M SOX D AND E n. mmun uleneaAATlf11.1 uun no N IP UNnrRnRniIN0. BOTH IF APPLICABLE i DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 5 INTERNAL BLADDER SYSTEM ❑ 95 UNKNOWN A. TYPE OF❑I SYSTEM I v. 2 SINGLE WALL ❑ 4 SINGLE WALL IN A VAULT ❑ 99 OTHER 1 SUCTION -E54 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/ FIBERGLASS REINFORCED PLASTIC B. TANK MATERIAL F7 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER D. LEAK DETECTION ❑ I RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY UNING ❑ 4 PHENOLIC LINING C. INTERIOR LINING OR ❑ 5 GLASS LINING 6 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO— D. EXTERIOR ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING 33 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC CORROSION ❑ s CATHODIC PROTECTION ❑ 91 NONE I�F� /I y5 UNKNOWN ❑ 99 OTHER PROTECTION SPILL CONTAINMENT INSTALLED (YEAR) T OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) DISPENSER CONTAINMENT YES NO E. SPILL AND OVERFILL, BIC. DROP TUBE YES _ NO _ STRIKER PLATE YES_ NO _ _ n. mmun uleneaAATlf11.1 uun no N IP UNnrRnRniIN0. BOTH IF APPLICABLE r TANIV I CAV I'1FTFCTIr)N • ❑,1 VISUAL CHECK �L�-y,/ 2 RECONCILATIONORV ❑ 3 VAOZEMONIITORING ❑ 4 GAUGINGAUTOMATIC TANK ❑ 5 MONITORINGROUNDWAG TESTING ❑ 8 TTESTINGNUAL TANK ❑ 7 CONMON INUOU INTERSTITIAL u8 SIR ❑ 9 WEEKLY MANUAL ❑ 10 MOTESTINGHLY TANK E]95 UNKNOWN ❑ 99 OTHER ORIN VI. TANK CLOSURE INFORMATION (PERMANENT CLOSURE IN -PUCE) 1. ESTIMATED DATE LAST USED (MO/DAY/YR) 2. ESTIMATED QUANTITY OF 3. WASTANK FILLED WITH YES [:]NO� SUBSTANCE REMAINING GALLONS INERT MATERIAL? 1 mirlco PPAIA/ T nF PFR. It /RY AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT rvnm nna v - TANK OWNER'S NAME DATE (PRINTED 6 SIGNATURE) LOCAL AGENCY USE ONLY THE STATE I.D. NUMBER IS UUMPubru Ur I Ne ruun numocw PCLV•. COUNTY B JURISDICTION N A �-�--FACILITY If TANK A STATE I.D.# PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE p /r THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION :FORM A, UNLESS A CURRENT FORM A HAS BEEN FILED. FORM C MUST BE COMPLETED FOR I TALLAATIONS. THIS FORM n.mnmNTlur TBR IINSWGROUNDSTORAGE TANK REGULATIONS •FORM B (6-95) FOR0074&RT A. SYSTEM TYPE A U 1 SUCTION tv 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 UNED 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 pO?95 UNKNOWN A U 99 OTHER - D. LEAK DETECTION ❑ M MECHNIIGLL UNE LFAK =mGA ❑ 2 UNE M.MNE56 3 LOMINUWS WfERSTIML 4 BEmDQr LINE O TESTING ❑ xoxnGRNG ❑ LEAK OETECrOR S AUfownc PUMP O 98 OTHER SMITUOWN r TANIV I CAV I'1FTFCTIr)N • ❑,1 VISUAL CHECK �L�-y,/ 2 RECONCILATIONORV ❑ 3 VAOZEMONIITORING ❑ 4 GAUGINGAUTOMATIC TANK ❑ 5 MONITORINGROUNDWAG TESTING ❑ 8 TTESTINGNUAL TANK ❑ 7 CONMON INUOU INTERSTITIAL u8 SIR ❑ 9 WEEKLY MANUAL ❑ 10 MOTESTINGHLY TANK E]95 UNKNOWN ❑ 99 OTHER ORIN VI. TANK CLOSURE INFORMATION (PERMANENT CLOSURE IN -PUCE) 1. ESTIMATED DATE LAST USED (MO/DAY/YR) 2. ESTIMATED QUANTITY OF 3. WASTANK FILLED WITH YES [:]NO� SUBSTANCE REMAINING GALLONS INERT MATERIAL? 1 mirlco PPAIA/ T nF PFR. It /RY AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT rvnm nna v - TANK OWNER'S NAME DATE (PRINTED 6 SIGNATURE) LOCAL AGENCY USE ONLY THE STATE I.D. NUMBER IS UUMPubru Ur I Ne ruun numocw PCLV•. COUNTY B JURISDICTION N A �-�--FACILITY If TANK A STATE I.D.# PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE p /r THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION :FORM A, UNLESS A CURRENT FORM A HAS BEEN FILED. FORM C MUST BE COMPLETED FOR I TALLAATIONS. THIS FORM n.mnmNTlur TBR IINSWGROUNDSTORAGE TANK REGULATIONS •FORM B (6-95) FOR0074&RT