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0- STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION-FORM B COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. EMARKNLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑EM ❑ 2 INTERIM PERMIT 5 CHANGE OF INFORMATION ] PERMANENTLY C❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE8 TANK REMOVEDFACILITY NAME WHERE TANK IS INSTALLED: D -�YY✓� oG �.✓ / I. TANK DESCRIPTION COMPLETE ALL ITEMS– SPECIFY IF UNKNOWN A OWNER'S TANK I.D.# (/ B. MANUFACTURED BY: C. DATE INSTALLED(MG/DAY/YEAR) —I D. TANK CAPACITY IN GALLONS: �pD II.TANK CONTENTS FA-11SMARKED,COMPLETE ITEM C. A ❑ 1 MOTOR VEHICLE FUEL 4 OIL g, C ❑ 1a REGULAR UNLEADED ❑ 3 DIESEL ❑ 6 AVIATION GAS ❑ 2 PETROLEUM ❑ 80 EMPTY ❑ 1 PRODUCT ❑ 1b PREMIUM UNLEADED ❑ 4 GASAHOL ❑ 7 METHANOL ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN 2 WASTE ❑ 1c MIDGRADE UNLEADED ❑ 5 JETFUEL ❑ 8 M85 D. IF(A i)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED ❑ 2 LEADED ❑ 9g OTHER(DESCRIBE IN REM O.BE LOW) \ rvus e C.A.S.#: O5 III• TANK CONSTRUCTION A IRK ONE ITEM ONLY IN BOXES A,S,AND C.AND ALL THAT APPLIES IN BOX D AND E A. TYPE OF ❑ 1 DOUBLE WALL\ ❑ 3 SINGLE WALL WITH EXTERIOR LINER SYSTEM ❑ 2 SINGLE WALL ❑ d SING ❑ 5 INTERNAL BLADDER SYSTEM ❑ 95 UNKNOWN LE WALL IN A VAULT ❑ 99 OTHER B. TANK ❑ 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS MATERIAL ❑ I STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC ❑ 5 CONCRETE 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM (Primary Tank) F-1 ❑ S 1METHANOL COMPATIBLE W/FRP 9 BRONZE 10 GALVANIZED STEEL E] 95 95 UNKNOWN ❑ gg OTHER C.INTERIOR ❑ 1 RUBBER LINED ❑ ALKYD LINING ❑ 3 EPDXY LINING LINING OR ED 4 PHENOLIC LINING ❑ 5 GLASS LINING ❑ 8 LINED COATING ❑ 95 UNKNOWN ❑ 99 OTHER OR IS LINING MATERIAL COMPATIBLE WITH 100° ETHANOL? YES_ NO— CORROSION O_ D CO ROTS ON ❑ 1 POLYETHYLENE WRAP ❑ 2 COAT ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODICPROTEI::: ❑ 81 NONE E]95 UNKNOWN ❑ 99 OTHER E.SPILL AND OVERFILL,6TC. SPILL CONTAINMENT INSTALLED NO (YEAR) ST OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) DROP TUBE VES_ ER PLATE VES NO_ IV. PIPING INFORMATION CIRCLE A IFABOVEGROUNDOR U IF DERGROUND,BOTH IF APPLICABLE DISPENSER CONTAINMENT YES_ NO__ A. SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY B. CONSTRUCTION A U 1 SINGLE WALL A U 2 DOUBLE WALL A U 4 FEPIPING A U 99 OTHER 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 S ALUMINUM A U 6 CONCRETE PROTECTION A U STEEL COATING A U 8 1METHANOL COMPATIBLE W/FRP A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION U 955 OTHER UNKNOWN A U 99 OTHER D. LEAK DETECTION E]1 MELHM'IL1L NNE IEAI( O 2 USE TIGMESS ❑3 CONTINUOUS INTERSTRIAL 4 ELECTRONIC UNE ❑5 AVlGIMRL WNR OElECiOR TESRNG MONITORING V.TANK LEAK DETECTION LM°EnCiOR 6NurwwN ❑ ss OTHER ❑ 1 VISUAL CHECK ❑ 2 MANUAL INVENTORY ❑ 3 VADOZE ❑ d AU MATIC TANK ❑5 GROUND WATER ❑ 6 ANNUAL TANK ❑ 7 CONTINUOUS INTERSTITIAL ❑ RECONCILIATION MONITORING GAU G MONITORING B SIR ❑ 9 WEEKLY MANUAL ❑10 MONT V TANK MONITORING TESTING TANK GAUGING TESTIN ❑ 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) 1.ESTIM�ED DATELA T USED pVryR) 2.ESTIMATED QUANTITY OF 12 � J SUBGALLONS STANCE REMAINING 3.WAS TANK FILLED WITH YES ❑ NO NS INERT MATERIALS THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT TANK OWNER'S NAME (PRINTED d SIGNATURE) PATE LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY# TANK# =NUMBER m-I PERMIT APPROVED BY/DATE PERMIT EXPIRATIONDATE THIS FORM MUST BE ACCOMPANIED BYNIA PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. FORM C MUST BE COMPLETED FOR INSTALLATIONS. THIS FORM SHOULD BE ACCOMPANIED BYA PL�OT,Py,, LE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE GROUND STORAGE TANK REGULATIONS FORM B (6.95) �]��A✓L"��f.�` / ,, C� �lP - GG p�Lt�N V GN Inc"),j"t.>2-ty � — / I LLL/`/