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• STATE OF CAUFORNIA STATE WATER RESOURCES CONTROL BOARD ~o 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 O 7 PERMANENTLY CLOSED ON SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 8 TEMPORARY TANK CLOSURE 'ZQ- 8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: Y G SLS I. TANK DESCRIPTION COMPLETE ALL ITEMS– SPECIFY IF UNKNOWN A OWNER'S TANK I.D.R ' B. MANUFACNflED BY: uvo C. DATE INSTALLED(MOIDAY/YEAR) /V D. TANK CAPACITY IN GALLONS: II.TANK CONTENTS IF A-1 IS MARKED,COMPLETE ITEM C. A Xj 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C, 1e REGULAR UNLEADED 3 DIESEL ❑ 8 AVIATON GAS ❑ 2 PETROLEUM ❑ 80 EMPTY 1 PRODUCT ❑ 10 PREMNM UNLEADED 4 GASAHOL ❑ 7 METHANOL ❑ 1c MIOGRADE UNLEADED ❑ 5 JET FUEL ❑ 8 M8.5 ❑ 3 CHEMICALPRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED ❑ 99 OTHER(DESCRIBE N ITEM D.BELON? D. IF(Al)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S.r 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 LINER ❑ 5 INTERNAL BLADDER SYSTEM 0 95 UNKNOWN SYSTEM ❑ 2 SINGLE WALL ❑ 4 SINGLE WALL IN A VAULT 99 OTHER B. TANK 1 BARE STEEL ❑ 2 STAINLESS STEEL E] 3 FIBERGLASS E:] 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL 5 CONCRETE ❑ 8 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP (P"MffY Tank) ❑ 9 BRONZE ❑ /0 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 ❑ 5 UNLINED JRZ 95 UNKNOWN ❑ 99 OTHER COATING IS LINING MATERIAL COMPATIBLE 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 E:, 99 OTHER SPILLCONTAINMENT INSTALLED(YEAR) OVERFlLL PREVENTION EQUIPMENT INSTALLED(YEAR) E.SPILL AND OVERFILLQOROPTUBE 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 4 FLEXIBLE PIPING 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 8 CONCRETE A U 7 STEEL W/COATING A U 8 100% 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 1 uEcxuacu uxE u"rz 2 u nD M 3 ca Nx NTBUTmu 4 BECiROMC uxE 5 Aurownc PuuP ❑ 9ETEcroR ❑ m nN9 ❑ MDNraIm+G ❑ UW( oETECTGx ❑ sKutoowx ❑ 99 o7HER V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 RECONCIL ATIONANUAL ORY r73 MON OZE ORING ❑4 GAUGINGIC TANK ❑5 MONITORING TER ❑ 8 TESTINGANNUAL TANK ❑ 7 MONITORING INTERSTITIAL ❑ 8 SIR ❑ 9 SEK GA=AL ❑ 10 MONTHLY TANK [395 UNKNOWN ❑99 OTHER TTING VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) 1.ESTIMATED DA LAST USE (MO/DAYNR) 2.ESTIMATED QUANTITY OF .}Q ID,tb 3.WAS TANKFILLEDWITH �5IALfT SUBSTANCE REMAINING ONS INERT MATERIAL 7 YES ISI NO❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THfgESTOKNOWLEDGE, IS TRUE AND CORRECT TANK OWNER'S NAME_-) �- DATE B (PRINTEDSIGNATURE) 1 , -_.., I c p �� D ' LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSEDDOF THE FO R NUMBERS BE OW COUNTY R JURISDICTION M FACILITY K TANK R STATE I.D.# m PERMIT NUMBER PERMIT APPROVED BYAOATE 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 PLAN. FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS FORM B (695)