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STATE OF CALIFORNIA `M1 STATE WATER RESOURCES CONTROL BOARD 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 ❑ 7 PERMANENTLY CLOSED ONSITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ B TANK REMOVED O DBA OR FACILITY NAME WHERE TANK IS INSTALLED: -7.7 vm Lvn I. TANK DESCRIPTION COMPLETE ALL ITEMS— SPECIFY IF UNKNOWN A OWNER'S TANK I.D.# Y/ B. MANUFACTURED BY: V C. DATE INSTALLED(MOIDAYNEAR) D. TANK CAPACITY IN GALLONS: II.TApNKK CONTENTS IF A-1 IS MARKED,COMPLETE ITEM C. A (11 7 MOTOR VEHICLE FUEL ❑ 4 OIL B. C. [-] 1a REGULAR UNLEADED ❑ 3 DIESEL ❑ 6 AVIATION GAS Ej ❑\2 PETROLEUM ❑ 80 EMPTY III 1 PRODUCT b PREMIUM UNLEADED O 5 ASAH L ❑ 8 M85 METHANOL ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE tc MIDGRADE UNLEADED ❑ 2 LEADED ❑ 99 OTHER(DESCRIBE IN TEM D.BELOM D. IF(A7)IS NOT MARKED, ENTER NAME OFSUBSTANCE 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 A. TYPE OF ❑ 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 5 INTERNAL BLADDER SYSTEM95 UNKNOWN SYSTEM ❑ 2 SINGLE WALL ❑ 4 SINGLE WALL IN A VAULT ❑ 99 OTHER 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 Lj 95 UNKNOWN ❑ 99 OTHER C.INTERIOR ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC UNING LINING OR ❑ 5 GLASS LINING ❑ 6 UNLINEDfN 95 UNKNOWN ❑ 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 1001,6 METHANOL? YES— NO— D.EXTERIOR ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC CORROSION PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE 95 UNKNOWN ❑ 99 OTHER E.SPILL AND OVERFILL,etc. 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 IF ABOVE GROUND OR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING U 99 O ER B. CONSTRUCTION A U 1 SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH Ag95 UNKNOWN 9 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 S 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&95 UNKNOWN A U 99 OTHER D. LEAK DETECTION ❑ HAN 1 MECHANICAL UNE LEAK [:] UN 2 E TIGMNES$ ❑ =MM MS WS INTERSTITIAL 4 ELECTRONIC UNE 5 AUTOMAOC PUNA DETECTOR TESTING MONITORING ❑ LEAK DETECTOR ❑ SHUTDOWN 99 OTHER V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 RECONCILIATIONANUAL INVENTORY ❑ 3 VADOZE MONITORING ❑ 4 AUTOMATGAUGING IC TANK 5 GROUND MON TORING�R ❑ 6 ANNUALTESTING ❑ 7 MONITORING INTERSTITIAL ❑ 8 SIR ❑ 9 WEEKLY MANUAL ❑10 MONTHLY TANK 95 UNKNOWN 99 OTHER TANK GAUGING TESTING ❑ VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PUCE) 1.ESTIMATEDDA T1.1;D(MO/DAYNR) 2 ESTSUBSTANED CEUANTITY OF O GALLONS 3 WASN FN MATERI WII?H 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 (PRINTED 8 SIGNATURE) LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY#1 �1 TANK# DD STATE I.D:# K O b 16 11 q It q141-q7 PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLIC N-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. FORM C MUST BE COMPLETED FOR INSTALLATIONS, THIS FORM SHOULD BE ACCOMPANIED BY A PLOT PLwLE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE GROUND STORAGE TANK REGULATIONS FORME (6-95) "��