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- . ^yWnc<a STATE OF CALIFORNIA ^^ `,� STATE WATER RESOURCES CONTROL BOARD o UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B �� �p�, COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY awl NEW PERMIT ❑ 3 RENEWAL PERMIT �5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ON SITE ONE ITEM 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: 0P_t_PWQ0 S I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A OWNER'S TANK I.D.# I B. MANUFACTURED BY: Tp'u SGO C. DATE INSTALLED(MO/DAYNEAR) Oc-T ql_ D. TANK CAPACITY IN GALLONS: 15 Qp IL TANK CONTENTS IFA-1 IS MARKED,COMPLETE ITEM C. A. 4�1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C. to REGULAR UNLEADED E] 3 DIESEL ❑ 6 AVIATION GAS ❑ 2 PETROLEUM ❑ 80 EMPTY 1� ' PRODUCT ❑ 1b PREMIUM UNLEADED ❑ 4 GASAHOL ❑ 7 METHANOL ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ Ic MIDGRADE UNLEADED ❑ 5 JET FUEL ❑ 8 M85 ❑ 2 LEADED ❑ 99 OTHER(DESCRIBE IN ITEM D.BELOW) D. IF(A.1)IS NOT MARKED, ENTER NAME OFSUBSTANCE 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 'IJI � DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 5 INTERNAL BLADDER SYSTEM ❑ 95 UNKNOWN SYSTEM ❑ 2 SINGLE WALL ❑ 4 SINGLE WALL IN A VAULT ❑ 99 OTHER B. TANK ❑ 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS 1�5<4 STEEL CUD 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 ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING 4 PHENOLIC LINING LINING OR ❑ 5 GLASS LINING ;!�r 6 UNUNED ❑ 95 UNKNOWN ❑ 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES>S� NO_ D.EXTERIOR ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP Cal FIBERGLASS REINFORCED PLASTIC CORROSION PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE E] 95 UNKNOWN ❑ 99 OTHER E SPILL AND OVERFILL,MC. SPILL CONTAINMEN I TALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) DROP TUBE VES NO_ STRIKER PLATE VES 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 A 02 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL AS 2 DOUBLE WALL A U 3 LINED TRENCH A U 85 UNKNOWN A U 99 OTHEJW/FRP 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 6 CONCRETE A U 7 STEEL W/COATING A U 8 IOD% METHANOL COMPATIBL PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION t MECNWIGL ME IFAK 2 ME FGN NESS 3 CCx LAWS IIERST 4 Euxmoxlc uxE 5 AUTOWTIC PUMP ❑ OEIECfOR ❑ TE51ING MMTORMO ❑ ITAx OEIECTOR SMI1pOWN 99 0714ER V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 MANUAL RECONCILIIATIONOgY ❑ 3 MONIITORING OZErx 4 GAUGNGAUTOMATIC TANK ❑5 MONITORINGGROUND ❑ 8 TESTINGTANK �7 CONTINUOUS MONITORING INTERSTITIAL ❑ g SIR ❑ 9 TANK GAUGINGAL ❑ 10 MOSTINGHLY TANK ❑ 95 UNKNOWN ❑ 99 OTHER TE VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) AAA . 1.ESTIMATED DATE LAST USED(MO/DAYNR) A r^ n - 2.ESTIMATED QUANTITY OF �� 3.WAS TANK FILLED WITH 'V fT SUBSTANCE REMAINING GALLONS INERT MATERIAL? �g THIS FORM HAS BEEN LETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS E AND CORRECT TANK OWNER' NAME D (PRINTED&SIG TURD I�f� �Jam- \ r, `/_ ) LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW /+✓T COUNTY# JURISDICTION# FACILITY# TANK# STATE 104 m 0 7 .5 0 7 PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE z � C, a THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. FORM C MUST BE COMPLETED FOR INSTALLATIONS.THIS FORM SHOULD BE ACCOMPANIED BY A PLOT PLfLE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UypERGROUND STORAGE TANK REGULATIONS FORM B (6-95)