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c, • STATE OFCAUFORNIA . I� STATE WATER RESOURCES CONTROL BOARD ••' r,.'' ,� UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B ;a COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY f ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ T PERMANENTLY CLOSED N SITE ONE REM ❑ 2 INTERIM PERMIT ❑ A AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED Q DBA OR FACILITY NAME WHERE TANK IS INSTALLED: I. TANK DESCRIPTION COMPLETE ALL ITEMS– SPECIFY IF UNKNOWN Ili 6110% A OWNER'S TANK I.D.a B. MANUFACTURED BY: J t C. DATE INSTALLED(MOMAYKEAR) I q 22 D. TANK CAPACITY IN GALLONS ILTANK CONTENTS IFA-11S MARKED,COMPLETE ITEM C. A ® 1 MOTOR VEHICLE FUEL ❑ l OIL B. C la AEGULAR UNFAOED 3 DIESEL ❑ 6 AVIATION GAS 10 PREMUM UNLEADED A GASAHOL T METHANOL ❑ 2 PETROLEUM ❑ 80 EMPTY 1 PROTECT tc MOGNDE UNLEADED 5 JET FUEL H 8 MBS ❑ 3 CHEMICAL PROIXICT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED g 99 OTHER(DESOMWITEMD.BELOW) O. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED GAS E: 111. TANK CONSTRUCTION MARK ONE TEM ONLY IN BOXES A.d AND C.AND ALL THAT APPLIES IN BOX D AND E A. TYPE OF 4101 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR UNER ❑ 5 KrERHAL BLADDER SYSTEM ❑ 95 UNKNOWN SYSTEM ❑ 2 SINGLE WALL ❑ d SINGLE WALL IN A VAULT 99 OTHER B. TANK ❑ 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS a STEEL CIAO W1 FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 5 POLYVINYL CHLORIDE ❑ 7 ALUMINUM r❑--` 8 10 METHANOL COMPATIBLE W/FRP (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER C.INTERIOR ❑ I RUBBER UNED ❑ 2 ALKYL LINING ❑ 3 EPDXY LINING ❑ 6 PHENOLIC UNING UNING OR ❑ 5 GLASS LINING 5 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER COATING IS UNING MATERIAL COMPATIBLE WITH 100% METHANOL] YES_ NO— D.EXTERIOR ❑ I POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ® A 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 ECUIPMENT 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 A FLEXIBLEPIPING A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL A(nZ DOUBLE WALL A U 3 UNED 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)AID FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U S CONCRETE A U 7 STEEL W/COATING A U 8 100 METHANOL COMPATIBLE WIFRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHOOICPR TECTION A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION [:1I 1 IIFoI"IarAL uxE IFAIc 2""9'w"T"Ecc GTFRouOUg NIE%1nML A ecsmolac uxE s Aurwwnc Puw ❑ ❑ fkTcGt,P ❑ 1FSfM YONT,fING U:AIf DETECI,R ❑ 9"ImT'M 99 ,THEA V.TANK LEAK DETECTION ❑ MONITORING 1 UAL CHECK ❑ 2 RECO CILU�wUAL NORY ❑ 3 MONOITZORING ❑ A AUTOM TIC TANK ❑5 MON ND WAS F76 TESTNGTANK NG 7 CONTINUOU ❑ 9 SIR S INTERSTITIAL ❑ 9 WEEKLY MANUAL ❑10 MONTHLY TANK L ❑ 95 UNKNOWN 99 OTHER TANK GAUGING TESTING VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) 1.ESTIMATED DATE LAST USED(MOIDAYNR) 2.ESTIMATED QUANTITY OF I 3.WAS TANK FILLED WITH YES ❑ NO ❑ SUBSTANCEREMAINING GALLONS INERT MATERIAL TEAS FORM HAS SEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT TANK OWNER'S NAME DATE !PRINTED A SIGNATURE) LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW STATE ILD:# COS.d-4�x JURISDICTIONa FAC® I TANK I j PERMIT NUMBER4�3S PERMIT APPROVED BY/DATE PERMIT EXPIRATION UAE r. T THIS FORM MUST BEACCOMPANIED BY A PERMRAPPUCATON-FORMA.UNLESS A CURRENT FORMA HAS BEEN RLEO.Fo MUST BE COMPLETED FOR INSTALLATIONS.THIS FORM SHOULD BE ACCOMPANIED BY PLOT Pt" ETHIS FORM WITH THE LOCAL AGENCY)MPI.ENENDNGTHE IIT OUNO STORAGE TANK REGULATIONS FORM B (695) • FORD0346 `lllclq �'