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' STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B , a I . COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. c'"'��`• MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED ONE REM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE 8 TANK REMOVED C) C jj DBA OR FACILITY NAME WHERE TANK IS INSTALLED: ,� $�,>I , �)fa - I. TANK DESCRIPTION COMPLETE ALL ITEMS– SPECIFY IF UNKNOWN ' A OWNER'S TANK I.D.If / B. MANUFACTURED BY: C. DATE INSTALLED(MO/DAY/YEAR) D. TANK CAPACITY IN GALLONS: II.TANK CONTENTS IF A•1 1S MARKED.COMPLETE ITEM C. 1A REGULAR UNLEADED 3 DIESEL ❑ 8 AVIATION GAS A 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C. ❑ ib PREMIUM UNLEADED n 4 GASAHOL ❑ 7 METHANOL ❑ 2 PETROLEUM ❑ 80 EMPTY 1 PRODUCT ❑ 1c MIOCMLADE UNLEADED I� 5 JET FUEL ❑ 8 M05 ' ❑ 3 CHEMICAL PRODUCT ❑ B5 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED ILJ-1 99 OTHER(DESCRIBE IN REM D.BELOW) D. IF(A1)IS NOT MARKED. ENTER NAME OF SUBSTANCE STORED C.A S.1: 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 ❑ 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR UNER ❑ 5 INTERNAL BLADDER SYSTEM ❑ 95 UNKNOWN SYSTEM 19 2 SINGLE WALL ❑ 4 SINGLE WALL IN A VAULT ❑ 99 OTHER t 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 (PHm9TY Tmk) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER ' C.INTERIOR ❑ 1 RUBBER UNED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOUC LINING LINING OR ❑ 5 GLASS LINING 6 UNUNED ❑ 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 91 NONE ❑95 UNKNOWN ❑ 99 OTHER PROTECTION ❑ s cASPILLCTHODIC CONTAINMENT SPILLCONTAINMENT IN ANO (YEAR) OVERFILL PREVENTION EQUIPMENTINSTALLED(YEAR) E.SPILL AND OVERFILL,lIC. DROP TUBE YES NO STRIKER PLATE VES_ NO ✓ DISPENSER CONTAINMENT YES_ NOA--- IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND,BOTH IF APPUCABLE A. SYSTEM TYPE A U 1 SUCTION A Q2 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION U 1 SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND <0 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 B 100% METHANOL COMPATIBLE W/PRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION 1 NEaw4cu Lm LEAN( 02 LINE 1rAnxLss 3 caxlxlws wlsAtmuL ❑4 EL[cmauc W ❑s AOrownc wLP ❑ ss OTHER 9E mm TEs1un YIX1TtlING NEN(9ETEctoa sHuroowx V.TANK LEAK DETECTION ' ❑ 1 VISUAL CHECK ❑ 2 RENRECO CIUATIONORV ❑ 3 VADOZEMONITORING ❑ 4 GADO G C TANK ❑ 5 GROUND MONITORING TESTING 6 ANNUAL TESTINGTANK ❑ 7 Co MON TOTING INTERSTITIAL ❑ 8 SIR ❑ 9 TANK1LGpUN AL ❑10 MONTHLY TANN ❑ 85 UNKNOWN ❑ 99 OTHER NG VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) ' 1.ESTIMATED DATE LAST USED(MO/DAY/YR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES ❑ NO I:/I. 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 DATE DATE (PRINTED A 51GNATURE)l LOCAL AGENCY USE ONL THE STATE I. .NUMBER IS C-44 POSED OF THE UR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY# TANK# STATE I.D.# c;' T PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE THIS FORM MUST BE ACCOMPANIED BY A PERMR AIION.FORMA,UNLESS A CURRENT FORM A HAS 'BEEN RM C NDERGRTBE COMPLETED FOR INSTALLATIONS. THIS FORM SHOULD BE ACCOMPANIED BY A PLO LAN. RLE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING UNDERGROUND S/0- TANK REGULATIONS " ,/ JL_ rrv�nR tc nsl �' '..