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a ,41110 STATE OF CALIFORNIASTATEWATEn RESOUPCES CONTROL BOAPD UNDERGROUND STORAGE TANK FERMcH APPS sCEMT10N FORM B COMPLETE A SEPARATE FORM FOR EACH ❑ T PERMANENTLY CLOSED ON SITE ❑ 5 CHANGE OF INFORMATION ❑ 8 TANK REMOVED 3 RENEWAL PERMIT ❑ 8 TEMPORARY TANK CLOSURE MARK ONLY t NEW PERMIT y AMENDED PER AT ONE ITEM 2 INTERIM PERMIT OBA OR FACILRY NAME WHERE TANK 'INSTALLED: I. t DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWNB MANUFACTUREDBY:AR'S TANK 1.D.Y 2O � 4—A&P!� �- � D. TANK CAPACITY IN GALLONS:C. INSTALLED(MOIDAY/YEAR) / K II.TANK CONTENTS IF A-1 1S MARKED,COMPLETE ITEM C. # REGU AR UN FADED ❑ 3 DIESEL ❑ 6 AVIATION GAS ❑ 4 OIL B. C' a ® 1 Moron VEHICLE FUEL E::3 ❑ tb PREMIUM UNLEADED ❑ 4 GASAHOL T METHANOL ❑ 2 PETROLEUM ❑ 80 EMPTY I PRODUCT O 1C MIDGRADE UNLEADED ❑ 5 JET FUEL ❑ 8 M85 ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED ❑ 99 OTHER(DESCRIBE IN ITEM D.BELOYn D. IF(AI)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S.#: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.8,AND C.AND ALL THAT APPLIES IN BOX D AND A. TYPE OF z I DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 5 INTERNAL BLADDER SYSTEM ❑ 95 UNW40VM SYSTEM ❑ 2 SINGLE WALL ❑ 4 SINGLE WALL IN A VAULT ❑ 99 OTHER B. TANK ❑ I BARE STEEL ❑ 2 STAINLESS STEEL 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM lyl 8 100% METHANOL COMPATIBLE W/FRP (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑] 99 OTHER C.INTERIOR ❑ I RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING LINING OR ❑ 5 GLASS LINING ❑ 6 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES JL NO— D.EXTERIOR O 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC CORROSION amu^ PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE ❑ 95 UNKNOWN 99 OTHER E.SPILL AND OVERFILL,etc. SPILL CONTAINMENT INST LED(YEAR) OVERFILL P ENTON EQUIPMENT INSTALLED(YEAR) DROPTUBE VES NO T IKER PLATE YES NO_ DISPENSER CONTAINMENT S 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 U 1 SINGLE WALL A 2 DOUBLE WALL A 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 U 3 POLYVINYL CHLORIDE(PVC)A 4 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL W/COATING A U 8 100% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION 4+c�1 "E�"""��uxE(EAI( ❑2 uxE rDKT"Ess 3 coxnxuas IxrERSTmu 4 ELECTRONIC U. O 5 AUf01MDC MW CEIECTOR TESTING MIXA UM LEAK OEIECTOR SX OW= ❑ 99 OTHER V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 MANUAL ❑ 3 VADO �4AUTOMATIC TANK NDWATER ❑ 6 ANNUNTANK 7NRNINTERSTITIAL OIL INVENTORY MONITORING NGMON ANNUAL TANK TOG 8 SIR ❑ 9 WEEK LY MANUAL O 10 MOTESTINGHLY TANK O 95 UNKNOWN E::]99 OTHER VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) 1.ESTIMATED DATE LAST USED(MO/DAWYR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES ❑ NO❑ SUBSTANCE REMAINING GALLONS INERTMATERIAL? THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT TANK OWNER'S NAME GATE (PRWTED A 6KIMTUHE) G - LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW STATE I.D:# COUNTY# JURISDICTION# FACILITY# TANK# ()0 PERMIT NUMBER PERMIT APPROVED BYIDATE PERMIT EXPIRATION DATE THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLIC-111-FORM A,UNLESS A CURRENT FORMA HAS BEEN FILED. FO""C MUST BE COMPLETED FOR INSTALLATIONS. THIS FORM SHOULD BE ACCOMPANIED BY A PLOT PL TLE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE RGROUND STORAGE TANK REGULATIONS FORM B (6-95) t"w �I