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STATE OF CALIFORNIA g.°":.��'., °6 STATE WATER RESOURCES CONTROL BOARD s dam, ,e UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B , ° 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. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN VtJ A OWNER'S TANK I.D.N T h D I { (,b Z B. MANUFACTURED BY: 41.4 L J C. DATE INSTALLED(MO'DAYNEAR) D. TANK CAPACITY IN GALLONS: II.TANK CONTENTS IF A-1 1S MARKED.COMPLETE ITEM C. A ❑ 1 MOTOR VEHICLE FUEL ❑ 4 OILB. C. ❑ Ie REGULAR UNLEADED 3 DIESEL ❑ 6 AVIATION GAS 21-2 PETROLEUM ❑ 80 EMPTY i PRODUCT ❑ 1b PREMIUM UNLEADED E] 4 GASAHOL E] 7 METHANOL ❑ Ic MIDGRADE UNLEADED ❑ 5 JET FUEL E] 8 M85 ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED ❑ 99 OTHER(DESCRIBE IN ITEM D.BELOW) D. IF(A1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A S.0: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A B,AND C,AND ALL THATAPPLIES IN BOX D AND E A. TYPE OF IE]I. i DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 5 INTERNAL BLADDER SYSTEM ❑ 95 UNKNOWN SYSTEM ❑ 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 ❑ 8 100% METHANOL COMPATIBLE W/FRP (PLI01M Teak) ❑ 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 N,95 UNKNOWN ❑ 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 10056 METHANOL? YES— NO— D.EXTERIOR ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC CORROSION PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE 9S UNKNOWN ❑ 99 OTHER SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) E.SPILL AND OVERFILL,lTC. 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 APPUCA13LE A. SYSTEM TYPE 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL A® 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 IPVC)A p 4 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL W/COATING A U B 100% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION [:]I x6cxxMcu.MEL6V( z ME rK,KTNss F-13 caxnMlous wrERsrn1AL ❑4 Eu:cmoxlc uNE ❑5 AurouAnc wuR ❑ 99 GTHER 9ElEC C TEE 1gMTORHG LTAx OETECfOR SXNnGWX V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 RMECO CILATIONORY ❑ 3 VAOZEMONIITORING ❑ 4 AUTOMATGAUGING MONITORING TANK E]5 GROUND MONTORINGTER ❑ 6 ANNUALTEESTNGTANK MONITORCONTINUOUS INTERSTITIAL ❑ 8 SIR ❑ 9 WEEKLY GAUGINGAL ❑10 MONTHLTESTING TANK E] 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) 1.ESTIMATED DATE UST USED MONDAY R) 2.ESTIMATED QUANTITY OF 0 3.WAS TANK FILLED WITH YES ❑ NO 5-' SUBSTANCE REMAINING SO GALLONS INERT MATERIAL 7 THIS FORM HAS BEEN COMP ED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT TANK OWNER'S NAME I DATE (PRINTED d SIGNATURE) 3 '� LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY N JURISDICTION N FACILITY N TANK N STATE I.D.# m = 6 / v 11 6 D PERMIT NUMBER PERMIT APPROVED BYIDATE PERMIT EXPIRATION DATE THIS FORM MUSTSHOULD BE ACCOMPANIED BY PERMIT LOT PLAN. FILE APPLICATION-FTHIS FORM ORM WITH THE LOUNLESS A CAL FORM A HAS BEEN FILED. FORM C MUST BE COMPLETED FOR NS.THIS FORM AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS FORM B (6-95)