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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 T PERMANENTLY CLOS ONE ITEM 2 INTERIM PERMIT ❑ D ON SITE 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSUREI1�i' 8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: "94,F5,0 C+J�OG I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN J A OWNER'S TANK I.D.N 3 B. MANUFACTURED BY: C. DATE INSTALLED(MO/OAV/YEAR) —J y_ D. TANK CAPACITY IN GALLONS: OoD II.TANK CONTENTS IFA-1 IS MARKED,COMPLETE ITEM C. A ❑ 1 MOTOR VEHICLE FUEL 4 OIL B. p ❑ fa REGULAR UNLEADED ❑ 3 DIESEL ❑ 6 AVIATION GAS ❑ 2 PETROLEUM �❑ 80 EMPTY ❑ 1 PRODUCT ❑ 1b PREMIUM UNLEADED ❑ 4 GASAHOL ❑ ] METHANOL ❑ 3 CHEMICALPRODUCT ❑ 95 UNKNOWN 2 WASTE ❑ is MIDGRADE UNLEADED ❑ 5 JET FUEL ❑ 8 M85 ❑ 2 LEADED ❑ 99 OTHER(DESCRIBE IN ITEM D. ELOW) D. IF(A.1)IS NOT MARKED, ENTER NAME OFSUBSTANCE STORED q W S C.AS.N: O III. TANK CONSTRUCTION RK ONE ITEM ONLY IN BOXES A,B.AND C,AND ALL THAT APPLIES IN BOX D AND E A. TYPE OF ❑ 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 5 INTERNAL BLADDER SYSTEM ❑ 95 UN OWN ❑ SYSTEM ❑ 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 LASTIC MATERIAL ❑ 5 CONCRETE 6 POLYVINYL CHLORIDE ❑ l ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP (Primary Tank) ❑ 9 BRONZE 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER C.INTERIOR ❑ 1 RUBBER LINED ❑ ALKYD LINING ❑ 3 EPDXY UNING ❑ 4 PHENOLIC LINING LINING OR ❑ 5 GLASS LINING ❑ 6 LINED ❑ 95 UNKNOWN ❑ Be OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 100° ETHANOL 7 YES_ NO— D.EXTERIOR ❑ 1 POLYETHYLENE WRAP ❑ 2 COATIN CORROSION ❑ 3 VINYL WRAP ❑ d FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER E.SPILL AND OVERFILL,etc. SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) DROP TUBE YES_ NO__ ST ER PLATE YES_ Na. DISPENSER CONTAINMENT VES_ Np IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF DERGROUND,BOTH IF APPLICABLE 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 U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND A U 1 BARE STEEL A U 2 STAINLESS STEEL A 3 POLYVINYL CHLORIDE(PVC)A U 4 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 6 CONCRETEA U STEELW/COATING A U PROTECTION A U 9 GALVANIZED STEEL A U /0 CATHODIC PROTECTION 8 100% METHANOL COMPATIBLE /FRP U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION ❑1 MECHANICAL LINE LEAN 2 E6TNG � ❑3 CMOONNOURWGS INTERSTmAL 4 ELECTRONIC LINE O 5 AUfOM1nC PUNP DETECTOR LEAK MITEUM ;H T' N ❑99 OTHER V.TANK LEAK DETECTION ED I VISUAL CHECK ❑ 7 CONTINUOUS INTERSTITIAL a 2 MANUAL RECONCILIATION INVENTORY ❑ 3 VADMONIOTORING ❑ d GAUG�IPP{JJ�G IC TANK ❑ 5 GROUND MONITORINGTER ❑ 6 TESTINGTANK MONITORING ❑ 8 SIR ❑ g WEEKLY GAUGING ❑ 10 ME8T1NGY TANK ❑ 95 UNKNOWN ❑ g9 OTHER VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PUDE) 1.ESTIM TED DATIE LAST USED MR) 2.ESTIMATED QUANTITY OF / SUGALLONS STANCE REMAINING 3.WAS TANK FILLED WIINERT MATERIALT ///YYTH YES ❑ NOx '''�� THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORR CT TANK OWNER'S NAME (PRINTED b SIGNATURE) DATE LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY# TANK# STATE I.D:# I � EPERMITBER PERMIT APPROVED BY/DATE TO L1 �J PERMIT EXPIRATION DATE THIS FORM MUST BE ACCOMPANIED NIA PERMIT APPLIC``��`` LLIION-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. FO C MUST BE COMPLETED FOR INSTALLATIONS. THIS FORM SHOULD BE ACCOMPANIED BY A PLOT PWLE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE4RGROUND STORAGE TANK REGULATIONS FORMS (6-95J��` Gi'Il�Y11'LtL