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STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B 1 COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY Ell NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ON SITE ONE REM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED U DBA Ofl FACILITY NAME WHERE TANK IS INSTALLED: X/ G ^ T S` 4-04 I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN B. MANUFACTURED BY: (/, ; A OWNER'S TANK I.D.# v,Yi, C. DATE INSTALLED(MO/DAY/YEAR) V. D. TANK CAPACITY IN GALLONS: dU II.TANK CONTENTS IF A-1 IS MARKED,COMPLETE ITEM C. ❑ to REGULAR UNLEADED ❑ 3 DIESEL ❑ 6 AVIATION GAS A 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C ❑ 1b PREMIUM UNLEADED ❑ 4 GASAHOL ❑ 7 METHANOL ❑ 2 PETROLEUM ❑ 80 EMPTY 1 PRODUCT ❑ 1c MIDGRADE UNLEADED ❑ 5 JET FUEL ❑ 8 M85 ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE 2 LEADED ❑ 99 OTHER(DESCRIBE IN ITEM D.BELOW) C.A-S.#: D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED 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 F❑�ppp��I DOUBLE WALL F-13 SINGLE WALL WITH EXTERIOR UNER 1:15 INTERNAL BLADDER SYSTEM El 95 UNKNOWN SYSTEM LN-,2 SINGLE WALL ❑ 4 SINGLE WALL IN A VAULT E:1 99 OTHER 0� 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS E] 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B. TANK ❑ 6 POLYVINYL CHLORIDE ❑ ] ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP MATERIAL ❑ 5 CONCRETE (PrimaryTank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER UNED ❑ 2 ALKYD LINING ❑ 3 EPDXY UNING ❑ 4 PHENOLIC LINING C.INTERIOR6 UNLINED E:195 UNKNOWN ❑ 99 OTHER LINING OR F-15 GLASS LINING COATING IS UNING MATERIAL COMPATIBLE WITH 100% METHANOL? YES— NO— D.EXTERIOR ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC CORROSION gl NONE 1!1195 UNKNOWN ❑ 99 OTHER PROTECTION ❑ 5 CATHODIC PROTECTION ❑ SPILL CONTTUAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) E.SPILL AND OVERFILL,etc. DROPBE YES_ NO STAIKERPLATE YES_ NO_ DISPENSER CONTAINMENT VES_ NO__ IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR 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 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 COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER 1 MELNNIIGL UNE LEAK 2 NNE i1GHiNE55 ❑3 CCIITMUWS INIERSTRAL ❑4.EtECiRONIC DNE ❑5 A =PUMP ❑ 99 OTHER D. LEAK DETECTION ❑ OE1=R ❑ TEsnxO MDMTDRIN9 1TAK OETEcroR V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 MANUAL?INVENTORY ❑ 3 ON VADOZE 4 GAUGWG AUTOMATIC TANK ❑5 MONITORINGROUND G TE ❑6 TEA14STINGRECONCTANK ❑ 7 MONITORING ON TOR NG INTERSTITIAL ❑ 8 SIR ❑ 9 TANK LY MANUAL ❑10 MO T HLY TAONTINUOUS NK 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES ❑ NO 1.ESTIMATED DATE LAST USED(MO VN SUBSTANCE REMAINING GALLONS INERT MATERIAL 7 THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDDGAE,EIS TRUE AND CORRECT TANK OWNER'S NAME (PRINTED a SIGNANRE7 LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY# TANK# STATE I.D.# FPEFIMIT PERMIT NUMBER PERMIT APPROVED SWDATE EXPIRATION DATE MUST BE C THIS FORM MUSST BE HOULD BE ACCOIED BY A MPANIED BY AIP OTL ON E THIS FORM WITH THE LOCAL AGE NC IMPLEMENTING TH FORMA UNLESSACURRIENT FORMA HASBEENFILED. C GROUND STORA EETA KR REGULATIONS THIS THIS FORM FORM 8 (6-95)