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aapo�acaa STATE OF CALIFORNIA `i STATE WATER RESOURCES CONTROL BOARD a mil »o UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B ( COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ T PERMANENTLY CLOSED ON SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED O Q DBA OR FACILITY NAME WHERE TANK IS INSTALLED: 'I7 G✓U9S 0P_o A/, Go'd 1 I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A OWNER'S TANK I.D.If V. r B. MANUFACTURED BY: v C. DATE INSTALLED(MO/DAYNEAR) v �T D. TANK CAPACITY IN GALLONS: ILTANK CONTENTS IFA-11S MARKED,COMPLETE ITEM C. A, 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C. ❑ 1a REGULAR UNLEADED ❑ 3 DIESEL ❑ 6 AVIATION GAS F-] 2 PETROLEUM ❑ 80 EMPTY 1 PRODUCT ❑ 1b PREMIUM UNLEADED ❑ 4 GASAHOL ❑ 7 METHANOL ❑ 10 MIDGRADE UNLEADED E] 5 JETFUEL E::] 8 M85 ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE fLsJE"`'2 LEADED ❑ 99 OTHER(DESCRIBE IN REM D.BELOM D. IF(A1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S.#: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.B,AND C,AND ALL THAT APPLIES IN BOX D AND E q A. TYPE OF ❑ 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR UNER ❑ 5 INTERNAL BLADDER SYSTEM 95 UNKNOWN SYSTEM F-12 SINGLE WALL ❑ 4 SINGLE WALL IN A VAULT ❑ 99 OTHER T B. TANK ❑ 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL n] 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 10CIA METHANOL? YES— NO— D.EXTERIOR ❑ i POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC CORROSION PROTECTION ED5 CATHODICPROECTION ❑ 91 NONE rN95 UNKNOWN ❑ 99 OTHER E.SPILL AND OVERFILL,BIC. SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) DROP TUBE YES_ NO_ STRIKER PLATE YES_ NO DISPENSER CONTAINMENT YES NO IV.PIPING INFORMATION CIRCLE A IFABOVEGROUNDOR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U i 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 2DOUBLE WALL A U 3 LINED TRENCH 0 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 U 4 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 5�7 L W/COATING A U 8 100% METHANOL COMPATIBLE WIFRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION AN 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION ' MECIOMM UNE WAK 2 UNE i1GHINE55 3 CGMINUOUS INTERSTCML 4 EUMON10 UNE 5 AViOMARC WMP ❑ O Mll [:] TEmNG M09TWING I� LEAK WrECTOR � SHUTDOWN 99 OTHERy JL- V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 MANUAL RECONCIUATIONORY ❑ 3 VADOZE MONITORING ❑ 4 GAUGING AUTOMATIC TANK 5 GROUND MON TORINGTER ❑ 6 ANNUALTESTING ❑ 7 CONTINUOUS MONITORING INTERSTITIAL ❑ B SIR ❑ 9 ANk GAUGINGAL ❑10 TESTING TANK 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) 1.ESTIMAE7D T& S�T USED(MO/DAV/YR) 2 ESTSUBSTANCE REMAININGQUANTITY OF O GALLON73.11A 3 WA VERT MATERIS TANK FILLED AL?H YES E::] 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 (PRINTED d SIGNATURE) LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION It r�FACILITY# TANK# STATE I.D.# J = I I 1 _ 1 -7 1 1 1 1 11 E 47 PERMIT NUMBER PERMIT APPROVED BYIDATE PERMIT EXPIRATION UAE THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLI�N-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. FC MUST BE COMPLETED FOR INSTALLATIONS.THIS FORM SHOULD BE ACCOMPANIED BY A PLOT P ILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING TH IRGROUND STORAGE TANK REGULATIONS FORM B (6-85)