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STATE OF CALIFORNIA ,± STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B >n 16 COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLO SITE ONE TEM ❑ 2 INTERIM PERMIT F-1 � 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE r8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A OWNER'S TANK I.D.# B. MANUFACTURED BY: 6/7 C. DATE INSTALLED(MONA@YEAR) D. TANK CAPACITY IN GALLONS: II.TANK CONTENTS IF A-1 IS MARKED,COMPLETE ITEM C. MOTOR VEHICLE FUEL ❑ 4 OIL B. C. ❑ 1a REGULAR UNLEADED ❑ 3 DIESEL ❑ 6 AVIATION GAS 1 A. ❑ 2 PETROLEUM ❑ 80 EMPTY �� PRODUCT ❑ lb PREMIUM UNLEADED ❑ 4 GASAHOL ❑ 7 METHANOL ❑ 1c MIDGRADE UMEADED ❑ 5 JET FUEL ❑ 8 M85 ❑ 3 CHEMICALPRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE LEADED ❑ 99 OTHER(DESCRIBE IN"EMD.BELOW) D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A S.#: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.8,AND C,AND ALL THAT APPLIES IN BOX D AND E A. TYPE OF F-] 11 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 5 INTERNAL BLADDER SYSTEM ❑ 95 UNKNOWN SYSTEM E2 '2 SINGLE WALL ❑ 4 SINGLE WALL IN A VAULT ❑ 99 OTHER B. TANK U ' BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 1o0% METHANOL COMPATIBLE W/FRP (Primary Tank) ❑ 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 Q 6 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER COATING IS LINING MATERIAL COMPATIBLEWITH100% METHANOL? YES— NO— D.EXTERIOR F] �— I 1 POLYETHYLENE WRAP 2_POATNG E] 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC CORROSION 91 NONE ❑95 UNKNOWN ❑ 99 OTHER PROTECTION F7s CATHODIC PROTECTION PILLOPTUBE CONTAINMENT STRIKER PLATE YES_ NO_ DISPENSE INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) E.SPILL AND OVERFILL, RYES_ NO_ R CONTAINMENT VES_ NO IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND,BOTH IF APPUCABLE 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 A 0 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 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 MECKNaCAL UNE IFAK 2 LINE TIGHTNEEa 3 COmINL'Wa INTERSrmAL ❑4 ELECTRONIC LINE ❑5 Am01MTIC PUNK ❑ 99 DTMER �•�, D. LEAK DETECTION ❑ of uos ❑ MMa ❑ MOMLORING UAN eETEcroR sxur0ovm V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 RMANUAL ECONCILIATION MONITORING El VADOZEMONIITORING ❑ 4 AUTOMATGAUGING MONITORING TANK ❑ 5 ONTORINGROUND TER ❑6 TESTINGTANK ❑ 7 CONTINUOUS G TANK INTERSTITIAL ❑ 8 SIR ❑ 9 LY MANUAL ❑10 MO T HLY TANK 95 UNKNOWN E:] 99 OTHER MO VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) 1.ESTIMATED DME T USED( AY R) 2.ESTIMATED QUANTITY OF t....44>� 3.WAS TANK FILLED WITH YES ❑ NO Or== SUBSTANCE REMAINING /y` GALLONS INERT MATERIALS THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KN WLEDGE,IS TRUE AND CORRECT TANK OWNER'S NAME 'LSA C--,- "&2e ,` +orDATE �/�/ O (PRINTED 451GNATURE) �T� /'� LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY# TANK#QOI STATE I.D.# m I J 0 7 8 e 18 8 a PERMIT NUMBER PERMIT APPROVED BYIDATE PERMIT EXPIRATION DATE THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. FOR C MUST BE COMPLETED FOR INSTALLATIONS.THIS FORM SHOULD BE ACCOMPANIED BY A PLOT PULE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE GROUND STORAGE TANK REGULATIONS FORMS (6-95)