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STATE OF CALIFORNIA rti°u;`tg e STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B , COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ❑ i NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY C �"@N'$1TE•. ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVE DBA OR FACILITY NAME WHERE TANK IS INSTALLED: --- I. TANK DESCRIPTION COMPLETE ALL ITEMS— SPECIFY IF UNKNOWN A. OWNER'S TANK 1.D.# ,. i —» B. MANUFACTURED BY: l�L C. DATE INSTALLED(MO/DAYNEAR) D. TANK CAPACITY IN GALLONS: 11.TANK CONTENTS IFA-1 IS MARKED,COMPLETE ITEM C. A. © 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C to REGULAR UNLEADED ❑ 3 DIESEL ❑ 6 AVIATION GAS ❑ 2 PETROLEUM ❑ 80 EMPTY ❑ 1 PRODUCT D 1h PREWUM UNLEADED ❑ 4 GASAHOL ❑ 7 METHANOL ❑ ❑ 3 CHEMICAL PRODUCT 1e MIDGRADE UNLEADED ❑ 5 JET FUEL ❑ 8 M85 El 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED ❑ 99 OTHER(DESCRIBE IN ITEM D.BEL©4Y) D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S.#: lll. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A,B,AND C,AND ALL THAT APPLIES IN BOX D AND E Ij� 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 { FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP (PrimaryTank) ❑ 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 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 E.SPILL AND OVERFILL,Etc, SPILL CONTAINMENT INSTALLED(YEAR) OVERFfLL PREVENTION EQUIPMENT INSTALLED(YEAR) DROP TUBE YES P" NO STRIKER PLATE YES ►t' 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(IJ 2 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION AU1 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 4 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 6 CONCRE'T'E A U 7 STEEL W/COATING A U 8 100% METHANOL COMPATIBLEW/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION I J-I'MECHAIJICAL LINE LEAK [--]2 UNE TIGHTNESS CONTINUOUS INTERSTITIAL 4 ELECTRONIC UNE �,5'ALrrOMATIC PUMP d �.rDETECTOR _ TESTING MONITORING LEAK DEFECTOR SHUTDOWN ❑ 99 OTHER V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 MANUAL RECONCILIATION MONITORING ❑ 3 VAOOZE MONIITORING 4 AUTOMATGAUGING MONITORING TANK ❑ 5 GROUND RONITORINGTER ❑ 6 TESTING 7 MONITORING INTERSTITIAL ❑ 8 SIR ❑ 9 WEEKLY MANUAL ❑ 10 MONTHLY TANK ❑ g5 UNKNOWN ❑99 OTHER L+ TANK GAUGNG TESTING _ VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE fN-ALAC °.� "X / 1.ESTIMATED DATE LAST USED(MO/DAY/YR) 2.ESTIMATED OUAfITITY 6F d(` 3.WAS TANK FILLED WITH SUBSTANCE REYAINING i%' GALLONS INERT MATERIAL? YES ❑ NO ❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PElEJAX,AND TO T y E BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT TANK OWNER'S NAME !f DATE (PRINTED d VGNATURE) -7, .! d Z 7/ _Z_] LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSELipF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION ItJ FACILITY# TANK# STATE I.D:# ,ITT;�(u/ -71 - PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLIC FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. FO MUST BE COMPLETED FOR INSTALLATIONS. THIS FORM SHOULD BE ACCOMPANIED BY A PLOT PLrE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE LROUND STORAGE TANK REGULATIONS FORM B (6.95)