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STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ON SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT E:] 6 TEMPORARY TANK CLOSURE 8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: 7!n ze ► 41 "1 o5G 3`Y I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A OWNERS TANK I.D.# OG� 0� B. MANUFACTURED BY: 140&4ef n C. DATE INSTALLED(MO/DAYNEAR) 1-1182) D. TANK CAPACITY IN GALLONS:'6SfD IL TANK CONTENTS IF A-1 IS MARKED,COMPLETE ITEM C. A 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C. to REGULAR UNLEADED 3 DIESEL ❑ 6 AVIATION GAS ❑ 2 PETROLEUM ❑ 80 EMPTY ® 1 PRODUCT ❑ 10 PREMIUM UNLEADED 4 GASANOL ❑ 7 METHANOL ❑ 1C MIDGRADE UNLEADED ❑ 5 JET FUEL ❑ 8 MBS ❑ 3 CHEMICAL PRODUCT ❑ 84 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#: 111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A B.AND C,AND ALL THAT APPLIES IN BOX D AND E A. TYPE OF ❑ I DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR UNER ❑ 5 INTERNAL BLADDER SYSTEM ❑ 95 UNKNOWN SYSTEM RX 2 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 (Pilmaly Twk) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER C.INTERIOR ❑ 1 RUBBER LINED ❑ 2 ALKYO LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING LINING OR ❑ 5 GLASS LINING ® 6 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 10D% METHANOL? YES_ NO— D.EXTERIOR ❑ I POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC CORROSION PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE ❑95 UNKNOWN 99 OTHER E.SPILL AND OVERFILL,BIC. SPILL CONTAINMENT I STALLED(YEAR) OVERFILL LPPREVENTION EQUIPMENT INSTALLED(YEAR) DROP TUBE YES NO STRIKER PLATE YES_yp_ NO DISPENSER CONTAINMENT YES_ NO IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION AL02 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION A 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 U 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 8 CONCRETE A U 7 STEEL W/COATING A AU5�8 100% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN Aly/99 OTHER IIW'1 D. LEAK DETECTION 1 Na:auMcu tue LFAK ❑2 UNE TNMmlE6S 3 CCN9MOWMING Uw( 9t ND0113 WTEAST CiROMC ZINE UTOIM9C PM.P ❑ DEIECTOII ® TESTING ❑4 EU: OETECfOR ❑5 Ai l 99 OTHER V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 RECONCILIATIONNUAL ORV ❑ 3 MAODOZE NIITORING ❑ 4 AUTOMATIC TANK ❑5 GROUNDWATER ®6 TESTINGTANK ❑ 7 CONTINUOUS INTERSTITIAL NITORING ❑ 8 SIR ❑ 97gNEKIOR AL ❑10 MOTESNTHLY TANK ❑ 95 UNKNOWN ❑99 OTHER NG VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN.PucE) 1.ESTIMATED DATE LAST USED(MO/OAYNR) 2.ESTMATED QUANTITY OF 3.WAS TANK FILLED WITH YES E] NO V*SUBSTANCE REMAINING GALLONS INERT MATERIAL? V 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 fllNi �61GN 46 CZ) LOCAL AGENCY USE ONLY THE ST I. UMBEWIS COMPOSED OF THE FOUR NUMBERS BELOW Ili COUNTY# JURISDICTION N FACILITY If �� TANK N STATE I.D:# = � Li�J PERMIT NUMBER PERMIT APPROVED BYIDATE PERMIT EXPIRATION DAT ,Ill,jjC1 THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. FORM C MUST BE COMPLETE FOR INSTALLATIONS. THIS FORM SHOULD BE ACCOMPANIED BY A PLOT P' RLE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THT 'ERGROUND STORAGE TANK REGULATIONS FORM B (6-95) `A, '..0,