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1 ' • ncl9 STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B , o I 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: 76 50 I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN 0. OWNER'S TANK I.D.k � B. MANUFACTURED BV: C. DATE INSTALLED(MO/DAY/YEAR) D. TANK CAPACITY IN GALLONS: 0 L II.TANK CONTENTS IF A-1 IS MARKED,COMPLETE ITEM C. ❑y1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C . to REGULAR UNLEADED 3 DIESEL ❑ 6 AVIATIONGAS 0. x 2 PETROLEUM ❑ 80 EMPTY 1 PRODUCT 1b PREMIUM UNLEADED 4 GASAHOL ❑ 7 METHANOL Y- ` to MIDGRADE UNLEADED ❑ 5 JET FUEL ❑ 8 M85 ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE 2 LEADED ❑ 99 OTHER(DESCRIBE IN ITEM D.BELOM 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 ❑ i DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 5 INTERNAL BLADDER SYSTEM ❑ 95 UNKNOWN A. TYPE OF 99 OTHER SYSTEM 2 SINGLE WALL ❑ ❑ B. TANK /'LX� 4 SINGLE WALL IN A VAULT A`1 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 COMPATIBLE W/FRP (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER C.INTERIOR ❑ 1 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 1001% METHANOL? YES— NO-Y D.EXTERIOR ❑ 1 POLYETHYLENE WRAP x 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC CORROSION ❑95 UNKNOWN ❑ 99 OTHER PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENT ON OUIPMENT INSTALLED(YEAR) DROP TUBE YES_ NO DISPENSERCONTAINMENT YES_ NO E.SPILL AND OVERFILL,etc. No sTR ER PLATE YES__ IV.PIPING INFORMATION CIRCLE A IFABOVEGROUNDOR U IF UNDERGROUND,BOTH IFAPPUCABLE 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 U 1 SINGLE WALL A U 2 DOUBLE WALL 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 STEEL A U 3 POLYVINYL CHLORIDE(PVC)A U 4 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 6 CONCRETE A 07 STEEL W/,COATING A U 8 100% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODICPROTECTION A U 95 UNKNOWN A U 99 OTHER — D. A&CKANICAL UNE LEAN 2 UNE i NESS E:]3 CONDNDW3 INiEPSTmAL ❑4 ELECmoNIC UNE ❑5 AVfOM1TC NMP 99 OTHER D. LEAK DETECTION E]' DETEDron ❑ TEsnNG MoxnDRlxD IEAX DETECTOR sxuf9Dvm V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ AMINO 2 RECONCILIATION ❑ 3 MONITORING VADOZE ❑ 4 GAUGING AUTOMATIC TANK ❑5 MONITORINGGROUND TER ❑ e TESTINGTANK ❑ 7 cownwous MONITORING INTERSTITIAL ❑ 8 SIR 9 WEEKLY MANUAL ❑10 MONTHLY TANK ❑ 95 UNKNOWN ❑ 99 OTHER TANK GAUGING TESTING VI,TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) 1.ESTIMATE DATE USED( /D 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 TRUE AND CORRECT DATE TANK OWNER'S NAME (PRINTED A SIGNATURE) �y LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW LS COUNTY# JURISDICTION# FACILITY# TANK# STATE I.D.# — 03 PERMIT NUMBER PERMIT APPROVED BYIDATE PERMIT EXPIRATION DATE A,0-6-1�j 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& FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTINGT♦ DERGROUND STORAGE TANK REGULATIONS FORM B (6-95) _ i s'-- q j$