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ow^te STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. 11 MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CL TE ONE ITEM ❑ 2 INTERIM PERMIT 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ a TANK REMOVED 1 12 DAA OR FACILITY NAME WHERE TANK 1S INSTALLED: C��/C I. TANK DESCRIPTION COMPLETE ALL ITEMS— SPECIFY IF UNKNOWN A OWNER'S TANK I.D.# G 14/4046?CZ- — �Vaac7_ B. MANUFACTURED BY: C. DATE INSTALLED(MOIDAYNEAR) /g D. TANK CAPACITY IN GALLONS: II.TANK CONTENTS IF A-1 IS MARKED,COMPLETE ITEM C. ,y 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C. ❑ 1 b AS PREMIUM UNLEADED ❑ 4 GASAHOL ❑ 7 METHANOL 172 PETROLEUM B0 EMPTY ❑ 1 PRODUCT ❑ ❑ 1c MIDGRADE UNLEADED 5 JET FUEL ❑ B 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.#: Ill. 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 ❑ 95 UNKNOWN SYSTEM ❑ 2 SINGLE WALL 4 SINGLE WALL IN A VAULT ❑ 99 OTHER B. TANK ❑ 1 BARE STEEL ❑ 2 STAINLESS STEEL 3 FIBERGLASS ❑ 4 STEEL CLAD WI FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE O 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100! METHANOL COMPATIBLE WIFRP (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER C.INTERIOR ❑ 1 RUBBER LINED r—I 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING LINING OR ❑ 5 GLASS LINING ❑ & UNLINED ❑ 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 ❑ 99 OTHER ate. SPILL CONTAINMENT IN LED(YEAR) OVERFILL P ENTION EQUIPMENT INSTALLED(YEAR) E.SPILL AND OVERFILL, DROP TUBE YES ✓ NO STRIKER PLATE YES NO DISPENSER CONTAINMENT YES NO IV.PIPING INFORMATION CIRCLE A IF ABOVEGROUND OR UI PF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION U 2 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER S. CONSTRUCTION An 1 SINGLE WALL A U 2 DOUBLE WALL AID 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)AG 4 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL WI COATING A U 8 9009 METHANOL COMPATIBLE WIFRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION MECHANICAL UNE LEAK [::]2 UNE TIGHTNESS CONTINUOUS INTERSTITIAL ®4 ELECTRONIC UNE AUTOMATIC PUMP DETECTOR TESTING MONITORING LEAK DETECTOR SHUTDOWVN [-] 99 C!71�ER V.TANK LEAK DETECTION MANUAL ❑ 1 VISUAL CHECK ❑ 2 RECONCILIATIONORY ❑ 3 VA OZOERING 4 AUTOMATIC TANK ❑ 5 GRON ND WATER ❑ 6 ANNUAGTANK CONTINUOUS INTERSTITIAL ❑ B SIR 719 TANK LY MANUAL ❑ 10 MONTHLYSTING TANK ❑ 95 UNKNOWN ❑ 99 OTHER MONITORING VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) e i9 ILG— 1.ESTIMATED DATE LAST USED(MOIDAYNR) 2.ESTIMATED QUANTITY 3.WAS TANK FILLED WITH YES ❑ NO ❑ SUBSTANCE REMAININ GALLONS INERT MATERIAL? THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJ RY,AND TOT BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT TANK OWNER'S NAME DATE (PRINTEDa SIGNATURE) �Jn7 // Q 7 /JF J f LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSE THE FOUR NUMBERS BELOW COUNTY# JURISDICTIONV FACILITY# TANK# STATS I.D:# L PERMIT NUMBER PERMIT APPROVED BYIDATE PERMIT EXPIRATION DATE THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLIC N-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. F0 MUST BE COMPLETED FOR INSTALLATIONS. THIS FORM SHOULD BE ACCOMPANIED BY A PLOT PL E THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE IWGROUND STORAGE TANK REGULATIONS FORMS (6-95)