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0 0 �°'�..,..9 c STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD i M1 UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B �� <a COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ON SITE ONE REM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE 8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: I I L3 ?1a AA 9 I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A OWNER'S TANK I.D.# .0-- / B. MANUFACTURED BY: C. DATE INSTALLED(MO/DAY/YEAR) 40VC D. TANK CAPACITY IN GALLONS: /v ODV IL TANK CONTENTS CONTENTS IFA-11S MARKED,COMPLETE ITEM C. A. N/1 1 MOTOR VEHICLE FUEL ❑ 4 OIL B.��yyy C. ❑ is REGULAR UNLEADED DIESEL ❑ 6 AVIATION GAS `yO�' 2 PETROLEUM ❑ 80 EMPTY 1 PRODUCT ❑ ib PREMIUM UNLEADED ED 4 GASAHOL ❑ 7 METHANOL ❑ 10 MIDGRADE UNLEADED ❑ 5 JET FUEL8 M85 ❑ 3 CHEMICALPRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED El 99 OTHEfl(D RISE IN ITEM D.BELOW) D. IF(A.1)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 E A. TYPE OF ❑ 1 DOUBLIE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 5 INTERNAL BLAD SYSTEM ❑ 95 UNKNOWN SYSTEM 2 SINGLE ALL ❑ 4 SINGLE WALL IN A VAULT ❑ 99 OTHER B. TANK 1 BARE STEE ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL 0 W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100 ETHANOL COMPATIBLE W/FRP (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN 99 HER C.INTERIOR ❑ 1 RUBBER UNED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING El/PHENOLIC LINING LINING OR ❑ 5 GLASS LINING ❑ 6 UNLINED ❑ 95 UNKNOWN 99 OTHER COATING IS LINING MATERIAL COMPATIB \WITH 100% 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 SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) E.SPILL AND OVERFILL,61C. DROP TUBE YES_ NO STRIKER PLATE YES NO_ DISPENSER CONTAINMENT YES_ NO IV.PIPING INFORMATION CIRCLE A IF ABOVE GROU OR U IF UNDERGROU .BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION A U 2 PRE URE A 3 GRAVITY A U 4 FLEXIBLEPIPING A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL A U 2DOUBL ALL 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 L A U 3 POLYVINYL CHLORIDE(PVC)A U 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 CATHODI PRO CTION A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION4 WMCNIC UNE 1 MECNAM, lF.AI( IGHTNESS 3 C i OWINU IMERSMAL UTOWnC PUNP ❑ ❑ DETECTORA UNE ❑2 LINE TTESTING MQNTC61N ❑ [FAN DETECTOR ❑5 ASHUTDOWN 99 MERV.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 MANUAL INVENTORY ❑ 3 VADOZEMONITORING ❑ 4 GAUGINAUTOMATG MONITORING TANK ❑ 5 GROUND MONTORINGTER ❑ 6 TESTING ❑ 7 MONITORING INTERSTITIAL ❑ 8 SIR ❑ 9 TANK GA MANGA 10 M.TINGY TANK ❑ 95 UNKNOWN ❑99 OTHER VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) 1.ESTIMATED DATE LAST UBED( R) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES ❑ NO SUBSTANCE REMAINING GALLONS INERT MATERIAL? THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUEAND 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 2 3 & COUNTY# JURISDICTION# FACILITY# TANK# STATE I.D.# Al 71 PERMIT NUMBER ERMIT APPROVED BYIDATE PERMIT EXPIRATION DATE THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-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 PULE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE LoGROUND STORAGE TANK REGULATIONS FORMS (6-95) _7 I