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`. STATE OF CALIFORNIA 'g STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION -FORM B COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. ❑ 5 CHANGE OF INFORMATION ❑ T PERMANENTLY CLOSED ON SITE 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 8 TANK REMOVED MARK ONLY O E] 4 AMENDED PERMIT ❑ 8 TEMPORARY TANK CLOSURE ONE ITEM 2 INTERIM PERMIT DBA OR FACILITY NAME WHERE TANK IS INSTALLED: I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN B. MANUFACTURED BY: X A)C C 0. OWNERS TANK 1.D.Y M / , G aX -7- /J'-1-7 ' � ,p D. TANK CAPACITY IN GALLONS: 2G Oq �p Ld Al C. DATE INSTALLED(MOIDAWYEAR) II.TANK CONTENTS FA-115 MARKED,COMPLETE ITEM C. REG UNLEADED 3 DIESE77] GAS A- �- MOTOR VEHICLE FUEL ❑ 4 OIL e. 0. ❑ 1b PREMIUM UNLEADED 4 GASAOL❑ 2 PETROLEUM80 EMPTY ❑ 1 PRODUCT Ic MIOGgADE UNLEADED S JET F❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED 99 O1H ❑ 3 CHEMICAL PRODUCT C.A S.Y D. IF(AI)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A,B.AND C.AND ALL THAT APPLIES IN BOX D AND E I DOEl WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER 5 INTERNAL BLADDER SYSTEM 95 UNKNOWN A. TYPE OF l�Sl. SYSTEM ❑ 2 SINGLE WALL ❑ 4 SINGLE WALL IN A VAULT ❑ 99 OTHER ❑ 2 STAINLESS STEEL ® 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B. TANK ❑ I BARE STEEL 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM 8 100% METHANOL COMPATIBLE W/FRP MATERIAL F-1 5 CONCRETE ❑ (PHmary TMk) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING C.INTERIOR B UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER L&/R'SI>L GL.Ff/ LINING OR ❑ 5 GLASS LINING ❑ COATING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_,Y_ NO— D.EXTERIOR ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC CORROSION gl NONE ❑95 UNKNOWN ❑ 99 OTHER PROTECTION ❑ 5 CATHODIC PROTECTION ❑ SPILL CONTAINMENT INSTALLED(YEAR) OVFILL PREVENTION EQUIPMENT INSTALLED(YEAR) E SPILL AND OVERFILL,MC. DROP TUBE YES_ NO STRIKER PLATE YESER_ NO DISPENSER CONTAINMENT YES_ NO_ IV.PIPING INFORMATION CIRCLE A IFABOVEGROUNOOR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION A 02 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)ry u /4 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U B CONCRETE A U 7 STEEL W/COATING A U 8 IW% METHANOL COMPATIBLE WIFRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER 1 I&CHN4LAL LINE LFAK 2 UNE TKJ Wnlz 3 CO NUNS Y ST 4 ELECTRGNIC NNE 5 AWT =PUMP D. LEAK DETECTION GEiECfoR — TESTING WWMING O IEAK CE =A I� wiff[M m ❑ 99 OTHER V.TANK LEAK DETECTION I❑I I VISUAL CHECK ❑ 2 MANUAL RECONCILATIONORY E] 3 VADMONOZE ITORING Y'E 4 AUTOMATIGAUGING MONITORING TANK ❑ 5 GROUND MONTORINGTER E::] 6 ANNUALTESTINGTNK 7 CONMON INUOU INTERSTITIA O 8 SIR ❑ 9 E K LY MANUAL ❑10 GING MONTHLY TANK E] 95 UNKNOWN E:]99 OTHER ESTING VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) 1.ESTIMATED DATE LAST USED(MO/DAY/YR) �// 2' SUBSTANCE REMAI NGFGALLONS 3ESTIMATED OUANTITY WAS ERT MATERIAL TANK FILLED 7H YES ❑ NO❑ 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 Q (PRINTED 4 SIGNATURE) (y i Z.• /� LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW r-�r� / COUmNTY# JURISDICTION# FACILITY#'I TANK# V� STATE I.D.# p PERMIT NUMBER PERMIT APPROVED BYIDATE PERMIT EXPIRATION DATE THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLIC')N-FORMA,UNLESS A CURRENT FORMA HAS BEEN FILED. FOP"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 B (6-95) �P �