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• STATE OF CALIFORNIASTATE WATER RESOURCES CONTROL BOARD • UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B oi` COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. ' EIDBA K ONLY ❑ 1 NEW PERMIT `'��.o.n� E ITEM ❑ ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 7 PERMANENTLY CLOSED ONSITE OR FACILITY NAME WHERE TANK IS INSTALLED: a�ZO ❑ s TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED I. TANK DESCRIPTIONO COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A OWNER'S TANK 1.D.# C_�II C. DATE INSTALLED(MO/DAY/YEAR) v � , B. MANUFACTURED BY: . lr. � . II.TANK CONTENTS IFA-11S MARKED,COMPLETE ITEM C. D. TANK CAPACITY IN GALLONS: �i QVC A 1 MOTOR VEHICLE FUEL 0401- B. ❑ 2 PETROLEUM ❑ C. 1e REGULAR UNLEADED ❑ 3 DIESEL ED AVIATION GAS 80 EMPTY 1❑ PRODUCT 1b PREMIUM UNLEADED 3 CHEMICAL PRODUCT ❑ 85 7 METHANOL UNKNOWN ❑ 2 WASTE ❑ 4 GASAHOL ❑ ❑ LEAUNLEADED DADE 2 ❑ ❑ D. IF(A-1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED ❑ 2 LEADED B M85 5 JETFUEL ❑ 99 OTHER(DESCRIBE IN REM D.BELOV✓) III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.B,AND C.AND ALL THAT APPLIES IN BOX D AND E C A.S.#: A. TYPE OF ❑ i DOUBLE WALL ❑ 3 SINGLE WALL WITH SYSTEMED EXTERIOR LINER ❑ 5 INTERNAL BLADDER SYSTEM �, ❑ 95 UNKNOWN 2 SINGLE WALL �q SINGLE WALL IN A VAULT B. TANK n\ BARE STEELED99 OTHER ❑ 2 STAINLESS STEEL MATERIAL ❑ 5 CONCRETE ❑ 3 FIBERGLASS ❑ q STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC (Primary Tank) ❑ 6 POLYVINYL CHLORIDE 7 ALUMINUM ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ a5 UNKNOWN ❑ 8 1METHANOL COMPATIBLE W/P-p C.INTERIOR ❑ 1 RUBBER LINED ❑ ❑ 99OOTHER ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING LINING OR E] 5 GLASS LINING ❑ 4 PHENOLIC LINING ❑ 8 UNLINED COATING 95 UNKNOWN ❑ IS LINING MATERIAL COMPATIBLE WITH 100,5 METHANOL? 99 OTHER D.EXTERIOR YES— NO— D❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE � SPILL CONTAINMENiINSTALLED ) UNKNOWN ❑ gg OTHER E.SPILL AND OVERFILL,etc. ogoP TUBE Yes (YEAR No OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAq) W.PIPING INFORMATION STRFUNDE GR YES NOP DISPENSE-CONTAINMENT YES_ CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND,BOTH IF APPLICABLE NO A. SYSTEM TYPE a®1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING p SINGLE WALL A U 2 DOUBLE WgLL U 99 OTHER B. CONSTRUCTION �1 A U 3 LINED TRENCH A U 95 UNKNOWN C. MATERIAL AND A U 1 BARE STEEL A U 2 STAINLESS STEEL p U 99 OTHER CORROSION A U 5 ALUMINUM A U 3 POLYVINYL CHLORIDE(PVC)A U 4 FIBERGLASS PIPE A U 6 CONCRETE A U 7 STEELW/COATING PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 8 100% METHANOL COMPATIBLE W/FRP D. LEAK DETECTION ❑i UEI �uNE IFA,It ❑2 u k TIGxTN35 A�5 UNKNOWN A U 99 OTHER _ TESTING ❑3 CGNfIN0005 INfEgSmiAl ❑4�=,,IC UK ❑5 AUTOMATIC PUIM MONTORING LEAK GETECTGR V.TANK LEAK DETECTION sxuToovm ❑ 9s OTHER ❑ I VISUAL CHECK UOUS INTERSTITIAL 2 RECONCILIATION INVENTORY ❑ 3 VADOZE MONITORING ❑ 4 AUTOMAGAUGINTIC TANK ❑5 GROUND WATER 6 ANNUAL TANK MONITORING ❑ B SIR ❑ 9 WEEKLY MANUAL ❑10 MONTHLY TANK MONITORING TESTING TANK GAUGING TESTING ❑ 95 UNKNOWN 99 OTHER V/. TANK CLOSURE/NFORMAT(QA/(PERMANENT CLOSURE IN-PLACE) 1.ESTIMATED DATE LAST F( /DAY R) 2.ESTIMATED QUANTITY OF n, SUBSTANCE REMAINING t✓ 3.WAS TANK FILLED NTH GALLONS INERT MATERIAL? YES ❑ NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT TANK OWNERS NAME (PRINTED 8 61GNATUREI DATE LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW C # JURISDICTION# FACILITY#� _ STATE I.D:# TANK# PERMIT NUMBER � 1_J y/z/ L/ PERMIT APPROVED BY/DATE RMIT EXPIRATION DATE THIS FOAM MUST BE ACCOMPANIED BY A PERMIT APPLI ON-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED, FORM C MUST BE COMPLETED FOR INSTALLATIONS. THIS FORM FORME (695) SHOULD BE ACCOMPANIED BY A PLOT PILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THEJWGROUND STORAGE TANK REGULATIONS