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• yyo°wcta STATE OF CALIFORNIA + °° STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B r o •r'es= . COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY GLAD pW 6�TE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOV DBA OR FACILITY NAME WHERE TANK IS INSTALLED: �l I. TANK DESCRIPTION COMPLETE ALL ITEMS— SPECIFY IF UNKNOWN A OWNER'S TANK LD.N A424w~ � S/T--�gdGT B. MANUFACTURED BY: QI/_/I-XIS G. DATE INSTALLED(MO/DAYNEAR) r9 f;r 1 v D. TANK CAPACITY !N GALLONS: �D�G✓�,\'l! 11.TANK CONTENTS IF A-1 IS MARKED,COOMMPLETE ITEM C. A V 1 MOTOR VEHICLE FUEL ❑ 4 OIL B, C ❑ 1a REGULAR UNLEADED ❑ 3 DIESEL ❑ 6 AVIATION GAS ❑ 2 PETROLEUM ❑ 80 EMPTY ❑ I PRODUCT ❑ PREMIUM UNLEADED ❑ 4 GASAHOL L] 7 METHANOL 1c MIDGRADE UNLEADED ❑ 5 JET FUEL E:] $ MBS ❑ 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.N: 111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A,B.AND C.AND ALL THAT APPLIES IN BOX D AND E A. TYPE OF l"J 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 GLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVAN2ED 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,Oto. SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR( DROP TUBE YES NO STRIKER PLATE YES NO DISPENSER CONTAINMENT YES NO d> IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION A�lq 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 3 LINED TRENCH A U 96 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 CONCRETE A U 7 STEEL WICOATING A U 8 100% 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 ❑1 MECHANICAL LINE LEAK I�2 LINE TIGHTNESS 3 CONTINUOUS WERSTMAL �I 4 ELECTRONfC UNE 5 AUTOMATIC PUMP DETECTOR L 1 TESTING MONITORING LEAK DETECTOR SHUTDOWN 99 OTHER V.TANK LEAK DETECTION ❑k VISUAL CHECK ❑ 2 MANUALIVENTORY ❑ 3 VADOZE 4GAUGING IC TANK ❑ 5 GROUND WATER ❑ 6ANNUATANK 7 CONTINUOUS INTERSTITIAL ❑ ORING TESTINGMONITOR3NG B SIR ❑ 9 WEEKLY MANUAL ❑ 10 MONTHLY TANK El95 UNKNOWN 1799 OTHER TANK GAUGING TESTING VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE)-. Al I.ESTIMATED DATE LAST USED(MOIDAYlYR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES ❑ NO ❑ SUBSTANCE.RE IMI G GALLONS INERT MATERIAL? THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF P RJU Y,AND191 THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT TANK OWNER'S NAME DA, ,E f (PRINTED d SIGNATURES / --r'J y A/1` 0 e c;' LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOS 19 OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTI # FACILITY# TANK# STATE E.D:# d - /01 ERMIT AP PERMIT NUMBER PPROVED BYIDATE PERMIT EXPIRATION DATE" THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLIC ' FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. FOWjg,MUST BE COMPLETED FOR INSTALLATIONS. THIS FORM SHOULD BE ACCOMPANIED BY A PLOT PLE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE 4WGROUND STORAGE TANK REGULATIONS FORM 8 (6-95)