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Now, STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION • FORM B 1 COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. ❑ ❑ ] PERMANENTLY CLOSED ON SITE MARK ONLY �' - 1 NEW PERMIT 3 RENEWAL PERMIT E] 5 CHANGE OF INFORMATION ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: OLTANK DESCRIPTION COMPLETE ALL ITEMS- SPECIE IF UNKNOWN 0. MANUFACTURED BV: XNER'S TANK L 0.aE INSTAULED(MO/DAYNEAR) ALPp/1.OX '� D. TANK CAPACITY IN GALLONS: �J OO D G.A LGt� II.TANK CONTENTS IF A-1 1S MARKED,COMPLETE ITEM C. a REGULAR UNLEADED ❑ 3 DIESEL ❑ B AV ATION GAS A (� 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C. lb PREMIUM UNLEADED ❑ 4 GASAHOL ❑ T METHANOL Y"'� ❑ 80 EMPT• ❑ 1 PRODUCT 1c MIDGRADE UNLEADED ❑ 5 JET FUEL ❑ S M85 ❑ 2 PETROLEUM ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED ❑ 99 OTHER(DESCRIBE IN TDA D.BELOWI D. IF(A1)IS NOT MARKED. ENTER NAME OF SUBSTANCE STORED C.A.S.s: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.B.AND C,AND ALL THAT APPLIES IN BOX D AND E ®,..1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER [:] 5 INTERNAL BLADDER SYSTEM E] 95 UNKNOWN A. TYPE OF ❑ ❑ 99 OTHER SYSTEM ❑ 2 SINGLE WALL 4 SINGLE WALL IN A VAULT ❑ 1 BARE STEEL ❑ 2 STAINLESS STEEL ® 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B. TANK MATERIAL ❑ 5 CONCRETE ❑ 8 POLYVINYL CHLORIDE ❑ ] ALUMINUM B 100% METHANOL COMPATIBLE W/FRP (PNmaTY Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER C.INTERIOR ❑ I RUBBER UNED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING LINING OR ❑ 5 GLASS LINING ❑ 6 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER 1-1130.(G44f S COATING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? VES_Li,-A6_ D.EXTERIOR ❑ I POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ® 4 FIBERGLASS REINFORCED PLASTIC CORROSION 9/ NONE ❑95 UNKNOWN E::] 99 OTHER PROTECTION ❑ 5 CATHODIC PROTECTION ❑ E SPILL AND OVERFILL,6l0. SPILL CONTAINMENTINST LED(YEAR) IKER PLATEOYES OVERFILL PREVENTION EQUIPMENTDSPENSER CONTNNMENT VES NO DROP TUBE VES NO_ �_ � IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION AU02 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 UNED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND A U I BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A0 4 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U ] STEEL W/COATING Ad)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 EZ ...UNE uAll E::)2 UNE TIGHTNESS ®3 OONRNUWS NreRSmut ❑4 EDEcmONIC UNE ❑5 AVI M MW ❑ 99 OTHER DETECTOR TESTING MONITORING UAR DETECTOR SNVTCO'MI V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 MANUAL RECONCIUATIONORV ❑ 3 MONIITORING OZE �4 GAUGING MONITORING TANK ❑ 5 GROUND MONTORINGTER ❑6 ANNUAL TESTING 7 MON TOR U INTERS(TIAL O 8 SIR ❑ 9 TANK LY MANUAL ❑ 10 MO T NG HLY TANK ❑ 95 UNKNOWN E::] 99 OTHER VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PUCE) 1.ESTIMATED DATE LAST USED(MO/DAY/YR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES ❑ NO.20 SUBSTANCE REMAINING _1Az GALLONS INERT MATERIAL 7 THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT TANK OWNER'S NAME DATE (PRINTED B SIGNANRE) G/ _ Z -77 LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY N JURISDICTION 6 FACILITY N TANK N STATE 01m PERMIT NUMBER PERMIT APPROVED BYIDATE PERMIT EXPIRATION DATE y THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLIC•-'ON-FORMA,UNLESS A CURRENT FORMA HAS BEEN FILED. FOR"C MUST BE COMPLETED FOR INSTALLATIONS.THIS FORM SHOULD BE ACCOMPANIED BY A PLOT PL ILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE RGROUND STORAGE TANK REGULATIONS FORM 8 (6-95) !� �!