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• STATE OF CALIFORNIA `'W�"' STATE WATER RESOURCES CONTROL BOARD ' o UNDERGROUND STORAGE TANK PERMIT APPLICATION-FORM B m�' =� I COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ ] PERMANENTLY CLOSED ON SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ® 8 TANK REMOVED O DBA OR FACILITY NAME WHERE TANK IS INSTALLED: ,U 1 47 -, " EJ 1 C. I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A OWNER'S TANK I.D.N o - B. MANUFACTURED BY: C. DATE INSTALLED(MO/DAII.11) / �I k, D. TANK CAPACITY IN GALLONS: to (200 II.TANK CONTENTS IF A-1 IS MARKED,COMPLETE ITEM C. A �T 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C. E::] la REGULAR UNLEADED 3 DIESEL ❑ 6 AVIATION GAS F—] EMPTYu2 PETROLEUM ❑ BO EMPTY t PRODUCT UNLEADED0 lb PREMIUM ❑ le MOORAGEU EADED ❑ 5 JETFUMETHANOL NOL EL ❑ 8 M85 ❑ 3 CHEMICALPRODUCT ❑ 95 UNKNOWN /❑ 2 WASTE ❑ 2 LEADED ❑ 99 OTHER(DESCRIBE IN ITEM D.BELOM D. IF(Al)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A S.N 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� 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 5 INTERNAL BLADDER SYSTEM ❑ 95 UNIC40WN SYSTEM L,lJ 2 SINGLE WALL ❑ 4 SINGLE WALL IN A VAULT ❑ 99 OTHER B. TANK C9 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ T ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP (perry Too) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER C.INTERIOR ❑ 1 RUBBER LINEDI❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC UNING LINING OR ❑ 5 GLASS LINING I p 6 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO— D.EXTERIOR ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC CORROSION PROTECTION ❑ 5 CATHODIC PROTECTION_[2� 91 NONE ❑95 UNKNOWN ❑ 99 OTHER E.SPILL AND OVERFILL,BIC. 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 U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION A SINGLE WALL A U 2 DOUBLE WALL A U 3 UNED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND A U BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A U 4 FIBERGLASS PIPE CORROSION A 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 A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION i Uw IA:CNANIGL UNE LAK O2 INE TMIMIEES O 3 fgMWUWS WENSnnAL O 4 BECIflONIC UNE ❑5 AVEOWnC NNP MOMTM ❑ 99 OTHER TATECTOR 1ES1MG MO OETEam SNU100?M V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 MANUAL I INVENTORY ❑ 3 VADOZEIATION ING ❑ 4 GAUL NGAUTOMATIC TANK E::]5 MON ND W TER ❑6 ANNUTESTINGTANK ❑ ? MON TOR NO NUOUS INTERSTITIAL ❑ 8 SIR ❑ 9 TANK GAUGANGAL ❑ 10 TES HLY TANK ❑ 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PUCE) 1.ESTI TED DATE LAST USED O/DAY 2.ESTIMATED QU NTITY OF 3.WAS TANK FILLED WITH YES NO,;S2' SUBSTANCE MAIMING5C] GALLONS INERT E]MATERIAL? /' IT2 THIS FORM HAS BEEN COMPLETED UNDER PENAL GIPERJ Y,AND TO THE BEST QFMY KNOWLEDGE, IS TRUE AND CORRECT T RS RINAMEGATE IA (PNTED a SIGNATUREI C'Vt C, /,1 w_ c �l, n , Z L' - LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR N MBERS BELOW STATE I.D:# COUNTY N JURISDICTION N FACILITY N C/l I TANK N PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE 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 PLAN. RLE THIS FORM WITH THELOCAL AGENCY IMPPLLI049-V EMMEENN�NINGG)THE U RGROUND STORAGE TANK REGULATIONS FORM 8 (S95) 0 U l { / L/ / v.s' 4p