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. • w«y �°'�..,.. cis STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD 3,,, e o UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B 'e; _ , ., o' I ��t1.O,.M�� COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. 1 NEW PERMIT❑ [:]❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSE MARK ONLY TE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT El TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: Al. T S—' Lcn I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN B. MANUFACTURED BY: v,�• A OWNER'S TANK I.D.k v, C. DATE INSTALLED(MO/DAV/YEAR) ✓ D. TANK CAPACITY IN GALLONS: 0.(] II,TANK CONTENTS IF A-1 IS MARKED,COMPLETE ITEM C. 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C, ❑ 1a REGULAR UNLEADED ❑ 3 -.--,L ❑ 8 AVIATION GAS A ❑ FQ 1 PRODUCT O iC MIlb RDGRADEEMIUM UUNLEADED ❑ 5 NLEADED 4 GETFUEL ❑ B M85 METHANOL 2 PETROLEUM 80 EMPTY ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE 2 LEADED ❑ 99 OTHER(DESCRIBE IN ITEM D.BELOW) D. IF(Ai)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 F-] 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 5 INTERNAL BLADDER SYSTEM E-195 UNKNOWN SYSTEM X1940 SINGLE WALL ❑ 4 SINGLE WALL IN A VAULT ❑ 99 OTHER B. TANK � 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 (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER C.INTERIOR ❑ 1 RUBBER LINED F72 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING LINING OR ❑ 5 GLASS LINING OKA 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 91 NONE �5 UNKNOWN ❑ 99 OTHER PROTECTION ❑ 5 CATHODIC PROTECTION SPILL CONTAINMENT INSTALLED(NEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) E.SPILL AND OVERFILL,810. PROP TUBE VES_ NO_ STRIKER PLATE VES__ NO_ DISPENSER CONTAINMENT YES_ 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 S. CONSTRUCTION CV1 SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND A 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 B 100% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODICPROTECTION A U 95 UNKNOWN A U 99 OTHER 1 MECHNNICPL LINE LEAK 2 LINE nGHTNE55 ❑3 W NUWS WBISTRNL ❑4 ELECTRONIC UNE E]5 A Ur nM D NNP [:] 99 OTHER D. LEAK DETECTION ❑ oE1EmGR ❑ MMING MoMTDRNG LEAN GE1EmoR sHUTOowx V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 RECONCILIATION RV E] 3 VADOZE El MONITORING 4 AUTOMATGAUGINGIC TANK ❑5 GROUND MONITORING TER ❑ 6 ANNUALTESTING ❑ 7 CON WORN INTERSTITIAL ❑ 8 SIR ❑ 9 TANEK GAUGINGAL ❑10 MONTHLY TANK 5 UNKNOWN ❑99 OTHER TORIN VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) 1.ESTIMATED DATE LAST USED(MO/D /YR'q2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES [—] NO SUBSTANCE REMAINING ._GALLONS INERTMATERIAL? THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT DATE TANK OWNER'S NAME (PRINTED 8 SIGNATURE) LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY# TANK# � STATE I.D.# m = PERMIT NUMBER PERMIT APPROVED BYIDATE PERMIT EXPIRATION DATE THIS FORM MUST BE ACCOMPANIED BY A PERMIT APP LIN•FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. FORM C MUST BE COMPLETED FOR INSTALLATIONS. THIS FORM SHOULD BE ACCOMPANIED BY I PLOTP TLE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE tv GROUND STORAGE TANK REGULATIONS FORM B (6-95)