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STATE OF CAUFORNIA STATE WATER RESOURCES CONTROL BOARD 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 ❑ 7 PERMANENTLY CLOSED ON SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE 0 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: 144-L—ST.gTE I�j4G,ILEl2—S 6 I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A OWNER'S TANK I.D.M oci I B. MANUFACTURED BY: C. DATE INSTALLED(MCIDAYNEAR) Lll✓ILAAJOWN D. TANK CAPACITY IN GALLONS: 2/oov C77fL— ILTANK CONTENTS IFA-11S MARKED,COMPLETE ITEM C. A ❑ 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C. la REGULAR UNLEADED ❑ 3 DIESEL ❑ 6 AVIATION GAS 2 PETROLEUM80 EMPTY ❑ 1 PRODUCT lb PREMIUM UNLEADED E] 4 GASAHOL ❑ 7 METHANOL Ipl ❑ ❑ tC MIDGRADE UNLEADED E] 5 JET FUEL ❑ 8 M85 ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN El WASTE ❑ 2 LEADED ❑ 99 OTHER(DESCRIBE IN ITEM D.BELOW) D. IF(Al)IS NOT MARKED. ENTER NAME OF SUBSTANCE STORED C.A.S.#: 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 ❑ 95 UNKNOWN SYSTEM I'Vt 2 SINGLE WALL ❑ 4 SINGLE WALL IN A VAULT ❑ 99 OTHER B. TANK I� 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP (PTITnaTy Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER C.INTERIOR ❑ I RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING LINING OR ❑ 5 GLASS UNING [5?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 1� PROTECTION E:] gt NONE 95 UNKNOWN 99 OTHER 5 CATHODIC PROTECTION Ly ❑ ❑ E.SPILL AND OVERFILL,#tC. SPILL CONTAINMENT INSTALLED(Y R) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) DROP TUBE 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 U / SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLEPIPING A U 99 OTHER B. CONSTRUCTION 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 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 8 100% METHANOL COMPATBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER 3 WE L D. LEAK DETECTION E]1 MECHNNICAL EAK ME T NE55 CCMINUWS IXIERSIRILL ❑4 ElEC1RONC UNE ❑5 Alff M= 99 OTHER W1fl ❑of mon TEmaa ❑ IaxnaRlx6 1£V!oETECTaR sNumowT+ V.TANK LEAK DETECTION I� ❑ 1 VISUAL CHECK ® 2 RECONCILIATION CILIATIONORV ❑ 3 VADOZE MONITOING ❑ 4 AUTOMATGAUL NGIC TANK ❑5 GROUND MONITORING ✓-"6 ANNUAL TESTING ❑ 7 MONITORING OG INTERSTITIAL ❑ B SIR ❑ 9 7pNK GAUD NGA ❑10 TES NGY TANK ❑ 95 UNKNOWN ❑99 OTHER VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE O-PUCE) 1.ESTATED DATE UShUSED(MO/DAY/YR) 2.ESTIMATED OUANTTY OF 3.WAS TANK FILLED WITH rSe U^ YES ❑ NO SUBSTANCE REMAINING TERIAL? THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PER Y,AND TO TH BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT TANK OWNER'S NAME � DAT�'jE'T( (PRWlD T451GNANRE)' ?IG LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUaqMBERS BELOW COUNTY# JURISDICTION# ACILITY# TANK# VU STATE I.Dl m iled PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE THIS FORM MUST BE ACCOMPANIED BY A PERMIT APP ON-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. C MUST BE COMPLETED FOR INSTALLATIONS. THIS FORM SHOULD BE ACCOMPANIED BY A PLOT APP* FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING TH ERGROUND STORAGE TANK REGULATIONS FORM B (6-95)