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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. 1:17 PERMANENTLY CLOSED ON SITE MARK ONLY ❑ 1 NEW PERMIT1--] 8RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ONE REM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ B TANK REMOVED O4'J4 DBA OR FACILITY NAME WHERE TANK IS INSTALLED: /D 4- 1. I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN B. MANUFACTURED BY: ev, K . A OWNERS TANK I.D.p v-X- D. TANK CAPACITY IN GALLONS: p(� C. DATE INSTALLED(MOIDAVNEAR) II.TANK CONTENTS IFA-1 IS MARKED,COMPLETE ITEM C. 1a R- JLAII JI ADED ❑ 3 DIESEL ❑ a AVIATIONGAS LED OTOR VEHICLE FUEL �4 OIL B. C. ❑ 1U PREMIUM UNLEADED ❑ 4 GASAHOL ❑ 7 METHANOL TROLEUM ❑ 80 EMPTY I 1 PRODUCT ❑ 1t MIDGRADE UNLEADED 5 JET FUEL ❑ 8 M85 HEMICALPRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED 99 OTHER IDESCRIBE IN TEM D.BELOYOOT MARKED, ENTER NAME OF SUBSTANCE STORED ,end O/L-. C.A.S.p III. TANK CONSTRUCTION MARK7MM B,AND C.AND ALL THAT APPLIES IN BOX D AND E g FMATERIAL DOUBLE WALLLL WITH EXTERIOR UNER 5 INTERNAL BLADDER SYSTEM I-V 95 UNKNOWN ALL IN A VAULT ❑ 99 OTHER `\SINGLE WALL BARE STEEL STEEL 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP CONCRETE BRONZE ❑ 10 GALVANIZED STEEL �95 UNKNOWN ❑ 99 OTHER 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING 4 PHENOLIC LINING C.INTERIOR F-16 UNLINED n5,95 UNKNOWN ❑ 99 OTHER LINING OR ❑ 5 GLASS LINING COATING IS LINING MATERIAL COMPATIBLE WITH 100-/. METHANOL? YES— NO— D.EXTERIOR ❑ 1 POLYETHYLENE WRAP O 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC CORROSIONE] 5 CATHODIC PROTECTION ❑ 91 NONE 95 UNKNOWN 99 OTHER PROTECTION COTAINVES_WENT INSTALLED(YEAR) OVERFILL PRENT YES NO VENTION EQUIPMENT INSTALLED(YEAR) E.SPILL AND OVDROPTUBENERFILL,BIC. NO_ STRIKER PLATE YES__ NO__ DISPENSER CONTAINME _ SPILL IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 9 OTHER B. CONSTRUCTION A U 1 SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A�85 UNKNOWN A U 99 OTHER C. MATERIAL AND A U i 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 STEELS/UNKNOWN A U 9910THEFl1. ETHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U III CATHODIC PROTECTION 1 MEClNMLAL LINE LEAK 2 UNE RGNTNE55 ❑3 CCrNUWS INTERSTIML ❑4 ELECTRONIC UNE ❑5 AmOMARC PUMP ® 99 OTHER D. LEAK DETECTION ❑ ❑ TESTING MONnORING LE41(DE1ECfOR S4UiDOWN CE EC OP V.TANK LEAK DETECTION 2 MANUAL INVENTORY ❑ 3 MONITORING ❑ 4 GAU NGIC TANK ❑ 5 MONTORINGGROUND TER ❑6 ANNUALTA ❑ 1 VISUAL CHECK ❑ RECONCIUATON 9 WEEKLY MANUAL ❑10 MONTHLY TANK 95 UNKNOWN ❑99 OTHER ❑ 7 MONITORINGINTERSTITIAL ❑ 8 SIR ❑ TANK GAUGING TESTING VI,TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) 2.ESTIMATED QUANTITY OF 3,WAS TANK FILLED WITH YES Q NO 1.ESTIMATED DATE' T USED(MO/DAV/YR) SUBSTANCE REMAINING �—GALLONS INERT MATERIAL? THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT TANK OWNER'S NAME (PRINTED a SIGNAIIIRE) LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW EDATE EIE] COUNTY# JURISDICTION kFACILITY p STATE I.Dl [� 0 0 PERMIT NUMBER PERMIT APPROVED BV/DATEI — NT FORM A HAS BEEN PERMIT EXPIRATION M C MUST BE COMPLETED FOR THIS FORM MUST SH BE ACCO PANIIED BY PERMID BY A PLOTPIIC N.FORMTHIS A RUNLESS AM WITH CURHE REAL AGENCY MPLEMENTINGFILEDTHEOR�GROUND STORAGE TAN��KIREGULATIIONS S. THIS FORM LD BE FORME (6-95) v Iv��^�. 61