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• fAfou�ctla STATE OF CALIFORNIA �i STATE WATER RESOURCES CONTROL BOARD ➢,��, e e UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B >n _ , COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ] PERMANENTLY CLOSED ON SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT E] 6 TEMPORARY TANK CLOSURE Aa TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: -7(p5-0 I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A OWNER'S TANK I.D.# B. MANUFACTURED BY: C. DATE INSTALLED(MO/DAY/YEAR) iGQ� D. TANK CAPACITY IN GALLONS: II.TANK CONTENTS IFA-I IS MARKED,COMPLETE ITEM C. A ❑ I MOTOR VEHICLE FUEL ❑ 4 OIL B. C, IS PEGNUW UNLEADED 3 DIESEL ❑ 6 AVIATION GAS ��/ ❑ ib PREMIUM UNLEPDFD ❑ 4 GASAHOL ❑ ] METHANOL X2 PETROLEUM ❑ 80 EMPTY DF�I PRODUCT ❑ 1c MIDGRADE UNLEADED ❑ 5 JETFUEL ❑ 8 M85 ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN /`❑ 2 WASTE ❑ 2 LEADED ❑ 99 OTHER(DESCRIBE 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.B.AND C.AND ALL THAT APPLIES IN BOX D AND E A. TYPE OF ❑ 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR UNER ❑ 5 INTERNAL BLADDER SYSTEM ❑ 95 UNKNOWN SYSTEM ;r<2 SINGLE WALL ❑ 4 SINGLE WALL IN A VAULT ❑ 99 OTHER B. TANK �I BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ B 100% METHANOL COMPATIBLEW/FRP (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER C.INTERIOR ❑ I RUBBER UNEQ ITS❑- 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING LINING OR E:] 5 GLASS LINING )[I 6 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER_ COATING IS LINING MATERIAL COMPATIBLE WITH 1001,6 METHANOL? YES_ NO->( D.EXTERIOR ❑ 1 POLYETHYLENE WRAP2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC CORROSION gt NONE 95 UNKNOWN 99 OTHER PROTECTION ❑ 5 CATHODICPROTECDON E] ❑ SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) E.SPILL AND OVERFILL,6I0. 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 APPUCABLE A. SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLEPIPING A U 99 OTHER B. CONSTRUCTION A 1 SINGLE WALL A U 2- 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)A U 4 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 6 CONCRETE ALa STEELW/COATING A U B 1DO% METHANOL COMPATIBLEW/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER I MEDNANIM UNE LEAK 2 UNE TIGHTNESS ❑3 OIXInN0005 INIERST L ❑4 ELEmRONIC UNE ❑5 AUTOMABC PUMP 99 OTHER D. LEAK DETECTION ❑ G CMR ❑ TESTING MGNTCBwG LEAK DETECTOR sxumovm V.TANK LEAK DETECTION E] 1 VISUAL CHECK ❑ 2 MANUAL RECONCI INVENTUATION RY ❑ 3 MONOITORING ❑ 4 GAUGING AUTOMATIC TANK ❑5 MONITORINGROUND G ❑ 6 TESTINGANNUALTANK ❑ 7 MON TOR NG INTERSTITIAL ❑ 8 SIR 9 WEEKLY MANUAL E]10 MONTHLY TANK E] 95 UNKNOWN ❑ 99 OTHER TANK GAUGING TESTING VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PUDE) 1.ESTIM TED fE S=USE M AV/VR) 2.ESTIMATED OUANTITV 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 TRUE AND CORRECT TANK OWNER'S NAME DATE (PRINTED 6 SIGNATURE) LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW ZD a 3 Lp d COUNTY# JURISDICTION# FACILITY# �� TANK#� STATE I.Dl � = L>�aJ u l PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION UATE THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORM A,UNLESS A CURRENT FORMA HAS BEEN FILED. FORM C MUST BE COMPLETED FOR INSTALLATIONS. THIS FORM FORM B (6-95)SHOULD BE ACCOMPANIED BY A PLOT PILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THEO�ROUI b STORAGE TANK S