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~ STATE OF CALIFORNIA *_Mw s� STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION -FORM B , 1 COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY 1 NEW PERMIT O 3 RENEWAL PERMIT O 5 CHANGE OF INFORMATION T PERMANENTLY CLOSED ONSITE ONE ITEM 2 INTERIM PERMIT a 4 AMENDED PERMIT O 6 TEMPORARY TANK CLOSURE 8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: 1. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A OWNER'S TANK I.D.N 3 q_ —Q / B. MANUFACTURED BY: V dG UYI C. DATE INSTALLED(MOIDAYNEAR) D. TANK CAPACITY IN GALLONS: e O U(./ II.TANK CONTENTS IFA-1 IS MARKED,COMPLETE ITEM C. A J�LI 1 MOTOR VEHICLE FUEL � 4 OIL B. C. 1a REGULAR UNLEADED 3 DIESEL 6 AVIATION GAS O 2 PETROLEUM O 00 EMPTY 1 PRODUCT El 1b PREMIUM UNLEADED 4 GASAHOL T METHANOL O 1e MIDGRADE UNLEADED O 5 JET FUEL O 8 M85 O 3 CHEMICALPRODUCT ED 95 UNKNOWN O 2 WASTE O 2 LEADED O 99 OTHER(DESCRIBE IN ITEM D.BELOW) D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE 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 O 3 SINGLE WALL WITH EXTERIOR LINER O 5 INTERNAL BLADDER SYSTEM 0 95 UNKNOWN SYSTEM 2 SINGLE WALL Q 4 SINGLE WALL IN A VAULT O 99 OTHER B. TANK fl I BARE STEEL O 2 STAINLESS STEEL r—] 3 FIBERGLASS O 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL O 5 CONCRETE O 6 POLYVINYL CHLORIDE F__j T ALUMINUM O 8 100% METHANOL COMPATIBLE W/FRP (Primary Tarek) O 9 BRONZE ED 10 GALVANIZED STEEL ED 95 UNKNOWN O 89 OTHER C.INTERIOR O 1 RUBBER LINED O 2 ALKYD LINING O 3 EPDXY LINING 4 PHENOLIC LINING LINING OR Q 5 GLASS LINING '*�K 6 UNLINED 95 UNKNOWN 0 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 1001A METHANOL? YES— NO— D.EXTERIOR O 1 POLYETHYLENE WRAP O 2 COATING F_� 3 VINYL WRAP O 4 FIBERGLASS REINFORCED PLASTIC CORROSION PROTECTION 5 CATHODIC PROTECTION O 91 NONE 95 UNKNOWN Q 99 OTHER E.SPILL AND OVERFILL,#1C. SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL 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 1 SUCTION A U 2 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 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 T STEEL W/COATING A U 8 100% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION go95 UNKNOWN A U 99 OTHER 1 MEDNNIILAE UNE IF.11( 2 UNE MI NE55 3 eIXR IUXJS IMERSTIRAL 4 EIEDIRCNN:UNE 5 AVm1M9C NNP D. LEAK DETECTION Q of UWI TESTING Mgaranlxo 1E4N oElEcron sNVl G O 99 OTHER V.TANK LEAK DETECTION 0 1 VISUAL CHECK 2 MANUAL INVENTOJUAL RECONCILIATIONRY ❑ 3 MONIITORING VAOZEO 4 AUTOMATGAUD NGIC TANK Q 5 MON TORIN(OUND W�TER6 TESTINGTANK O T MONITORING INTERSTITIAL 8 SIR ❑ 9 TpNEK GAUGING TESTING❑10 TESTMINGY TANK 95 UNKNOWN 99 OTHER VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) 1.ESTIMATED DATE LAST USED(M AY 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YE NO SUBSTANCE REMAINING GALLONS INERT MATERIAL 7 ""�Yc' 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 (PRINTED 8 SIGNATURE) LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY# TANK# no STATE I.D.# PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLIrATION-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' FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING TH' iERGROUND STORAGE TANK REGULATIONS FORMS (6-95) ll/ '"low