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• STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD 3`'` ,s cam' UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B �� COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY 1 NEW PERMIT ❑ 3 RENEWAL PERMIT X5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY C ONE TEM 2 INTERIM PERMIT F-14 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: �1975'f tw� 74 I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A OWNERS TANK L D.# B. MANUFACTURED BY: -Tp v s G a C. DATE INSTALLED(MO/DAV/YEAR) v(fT- D. TANK CAPACITY IN GALLONS: c ooO [I.TANK CONTENTS IFA-1 IS MARKED.COMPLETE ITEM C. A P�rl MOTOR VEHICLE FUEL ❑ 4 OIL B. � C ❑❑.1a REGULAR UNLEADED ❑ 3 DIESEL ❑ 6 AVIATION GAS ❑ 2 PETROLEUM ❑ 80 EMPTY 4� PRODUCT L^J 1b PREMIUM UNLEADED ❑ 4 GASAHOL E:] 7 METHANOL It MIDGRADE UNLEADED 5 JET FUEL ❑ 8 M85 ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ ❑ ❑ 2 LEADED ❑ 99 OTHER(DESCRIBE IN ITEM D.BELOYO D. IF(Al)IS NOT MARKED, ENTER NAME OFSUBSTANCE STORED C.A.S.#: 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 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 �14 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE WA=RP (Primary Tak) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER C.INTERIOR ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY UNING ❑ 4 PHENOLIC LINING LINING OR ❑ 5 GLASS LINING � UNLINED ❑ 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 �K4 FIBERGLASS REINFORCED PLASTIC CORROSION PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE T ❑95 UNKNOWN ❑ 99 OTHER E.SPILL AND OVERFILL,lCC. SPILL CONTAINMENT ED(YEAR)STALLOVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) DROP TUBE YES NO STRIKER PLATE YES 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 2 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL A OU 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 ®FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL W/COATING A U B 100% METHANOL COMPATIBLE WIFRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION 1 :c6."ce uN LE1K 2 UNE TIGMNEGG-K 3 COMINUWS NiFA mw ❑4 E�Ec 0 UW JK5 AuraunC.. 9ETEGTOII TESTING 1�1 WMTORING LEAK O CTW ISI MM wl ❑ 99 OTHER V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 MANUAL RECONCILIATIONNENORY ❑ 3 MONIITORING OZE �4 GAUGING MONITORING TANK ❑5 GROUND MONTORINGTER F-16 TESTING 7 MONITORINGUINTERSTITIAL ❑ 8 SIR ❑ 9 TAENEKKGLY A=AL ❑10 MONTHLY TANK ❑ 95 UNKNOWN ❑ 99 OTHER TESTING VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PUCE) Aj.A . 1.ESTIMATED DATE LAST USED(MO/DAYNR)rY/ /�. 2.ESTIMATED QUANTITY OF �- 3.WAS TANK FILLED WITH T•i r� / SUBSTANCE REMAINING GALLONS INERT MATERIAL? YE THIS FORM HAS BEEN C M L D UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT TANK OWNERS PAME D (PRINTED d SIGNS REI / p ,• ' \�, i (�_ LOCAL AGENCY U E STATE I .NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY 77� TANK#rv. , STATE I.D:# m 0 7 ill(, PERMIT NUMBER PERMIT APPROVED BV/DATE PERMIT EXPIRATION DATE ^ V f7 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 INSTALLLATI NS. THIS FORM SHOULD BE ACCOMPANIED BY A PLOT PLRLE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE a GROUND STORAGE TANK REGULATIONS FORM B (6 95)