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STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD �yd98 u o UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT [D 5 CHANGE OF INFORMATION ❑ 7M O E ONE ITEM ❑ 2 INTERIM PERMIT r74 AMENDED PERMIT E] 6 TEMPORARY TANK CLOSURE rW 8 NK R VE DBA OR FACILITY NAME WHERE TANK IS INSTALLED: -7& aC.1 0>45&154 ) I. TANK DESCRIPTION COMPLETE ALL ITEMS— SPECIFY IF UNKNOWN A OWNER'S TANK 1.D.Y Q41 — p3 I B. MANUFACTURED BY: HC),4 e(n VJ6J611Y10 C. DATE INSTALLED(MO/DAY/YEAR) 101 D. TANK CAPACITY IN GALLONS: 18 II.TANK CONTENTS IFA-1 IS MARKED,COMPLETE ITEM C. A 64 / MOTOR VEHICLE FUEL ❑ d OIL S. C. 1a REGULAR UNLEADED 3 DIESEL ❑ 6 AVIATION GAS r-12 PETROLEUM ❑ 80 EMPTY IR 1 PRODUCT ❑ 1G PREMIUM UNLFAOFD d GASAHOL ❑ 7 METHANOL EllcMIDGRADE UM.EAOED 5 JET FUEL E] 8 M85 El CHEMICALPRODUCT ❑ 85 UNKNOWN El WASTE ❑ 2 LEADED 99 OTHER(DESCRIBE IN ITEM D.BELOM 0. IF(A.1)IS NOT MARKED, ENTER NAME OFSUBSTANCE STORED C.A.S.M: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A,8.AND C.AND ALL THAT APPLIES IN BOX D AND A. TYPE OF 7 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 5 INTERNAL BLADDER SYSTEM ❑ 95 UNKNOWN SYSTEM I__ 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 (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER C.INTERIOR ❑ I RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING LINING OR ❑ 5 GLASS LINING ® 6 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO— D.EXTERIOR ❑ I POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC CORROSION zv PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE ❑95 UNKNOWN ❑ 99 OTHER E.SPILL AND OVERFILL,BIC. SPILL CONTAINMENT I TALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) DROP TUBE YES NO_ STRIKER PLATE YES—JZ�h_ NO_ DISPENSER CONTAINMENT YES_ NO IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND,BOTH IFAPPLICABLE A. SYSTEM TYPE A U 1 SUCTION ACO2 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 IPVC)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 1COMPATITIyBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A�89 OTHER ! j IrV'1 0. LEAK DETECTION 1 MECNANICM UNE UAL( ®2 LNE VWKSS ❑3 CO MWS INTERSTIT L ❑4 ELECTR G tM C:] M 5 Aa NC NMP OETECTdI TESRNG MGMTGRNG LEAK GETECTm SHUTO C3 99 OTHER V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 RECONCILIATIONANUAL ORY [:] 3 M�TORING ❑ 4 AGAAUGUTONAGTIC TANK ❑5 MONITORINGTER 8 TESTINGGROUND ANNUAL TANK ❑ 7 MONITORCONTINUOUS ❑ 8 SIR ❑ 9 WANK LA M IN ❑10 MONTHLY TANK ❑ 95 UNKNOWN ❑99 OTHER TG TESTING_ 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 SUBSTANCE REMAINING GALLONS IN MATERIAL 7 THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT TANK OWNER'S NAME l� DATE RINT 610N REI (r 6n2 (OF LOCAL AGENCY USE ONLY THE ST I. MB IS COMPOSED OF THE FOUR NUMBERS BELOW lza CQUNIX Y JURISDICTION 0 FACILITY M NK N STATE I.D:# PERMIT NUMBER if I tERMIT APPROVED BY/DATE PERMIT EXP ATION ATE THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLIr4TION-FORM A,UNLESS A CURRENT FORMA HAS BEEN FILED. FORM C MUST BE COMPLETED FOR INSTALLATIONS.THIS FORM SHOULD BE ACCOMPANIED BY A PLOT- FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING TP TERGROUND STORAGE TANK REGULATIONS FORM 8 (6.85) `�