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• STATE OF CALIFORNIA • '<'; STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B I COMPLETE A SEPARATE FORM FOR EA ANK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOS TE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 6 TANK REMOVED fYI DBA OR FACILITY NAME WHERE TANK IS INSTALLED: (��j I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A OWNER'S TANK I.D.X � B. MANUFACTURED BY: 42. C. DATE INSTALLED(MO/OAWYEAR) D. TANK CAPACITY IN GALLONS: P78 (, II,TANK CONTENTS IF A-1 IS MARKED,COMPLETE ITEM C. to REGULAR UNLEADED ❑ 3 DIESEL ❑ 6 AVIATION GAS A 1 MOTOR VEHICLE FUEL ❑ d OIL B. I/ C. ❑ 1b PREMIUM UNLEADED ❑ 4 GASAHOL ❑ 7 METHANOL ❑ 2 PETROLEUM ❑ 60 EMPTY frJ/1 PRODUCT ❑ is MIDGRADE UNLEADED ❑ 5 JETFUEL ❑ 6 MBS ❑ 3 CHEMICALPRODUCT ❑ 85 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED ❑ 99 OTHER(DESCRIBE IN ITEM D.BELOW) D. IF(AI)IS NOT MARKED, ENTER NAME OFSUBSTANCE STORED C.A.S.N: 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 UBLE WALL F] 3 SINGLE WALL WITH EXTERIOR LINER E] 5 INTERNAL BLADDER SYSTEM E:] 95 UNKNOWN SYSTEM 2 SINGLE WALL ❑ 4 SINGLE WALL IN A VAULT ❑ 99 OTHER B. TANK 1 BARE STEEL F72 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 F-11 RUBBER LINED ❑ D LINING ❑ 3 EPDXY LINING [—] d PHENOLIC LINING LINING OR ED GLASS LINING 6 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO— D.EI(TERIOR ❑ 1 POLYETHYLENE WRAP ❑ 2 NG ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC CORROSION 91 NONE 95 UNKNOWN E::] 99 OTHER PROTECTION E] 5 CATHODIC PROTECTION 91 SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) E.SPILL AND OVERFILL,fisc. DROP TUBE YES - NO_ STpIKER PLATE YES_ NO._ DISPENSER CONTAINMENT YES_ NO_ IV. PIPING INFORMATION CIRCLE A IFABOVEGROUNDOR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION An 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 U 7 STEEL W/COATING A U a 100% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A 95 UNKNOWN A U 99 OTHER — I MEIXWICAL UNE IFAK2 UNE BGNN995 ❑ C 3 XMNU INTERST ❑4 ELECLRONIL UNE ❑5 AVf01MPL%INP ❑ 99 OTHER D. LEAK DETECTION F-1 L CTOR ❑ TESTMO MMTMM [ENt oETELTGR sHureowx V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK 2 MANUAL INVENTORY ❑ 3 ❑ 4 GAUGING AUTOMATIC TANK E:] 5 GROUND MONITORING TESTING RECONCILIATION MONITORING ❑ 7 MONITOfl NG INTERSTITIAL ❑ B SIR ❑ 9 TA KGAUGINGAL ❑10 MONTHLTESTING TANK ❑ 95 UNKNOWN ❑99 OTHER VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) 1.ESTIMATED DATE LAST USED(MOIDAYNA) 2.ESTIMATED OUANTITY OF 3.WAS TANK FILLED WITH YES ❑ NO ❑ SUBSTANCE REMAINING GALLONS INERT MATERIAL 7 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 (PRINTE0461GNANREI LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION N FACILITY It TANK N STATE I.D:# F5 RIZZI PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE yp THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. FOE MUST BE COMPLETED FOR INS LATIOONS. IS FORM SHOULD BE ACCOMPANIED BY A PLOT PLSRLE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING 7H RGROUND STORAGE TANK REG ATIONS FOR00]46R1 FORM B (6.95)