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STATE OF CALIFORNIA , STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B sn _ 1 COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT k 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ON SITE ONE ITEM E] 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: 5110 , I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A OWNER'S TANK I.D.# B. MANUFACTURED BY: C. DATE INSTALLED(MO/DAYNEAR) D. TANK CAPACITY IN GALLONS: II.TANK CONTENTS IF A-1 IS MARKED,COMPLETE ITEM C. 1 MOTOR VEHICLE FUEL ❑ 4 OIL B.�-y C. ❑ to PREMIUM UNLEADED IM UNLEADED ❑ 3 DIESEL ❑ 8 AVIATIONGAS lb SAHOL A 2 PETROLEUM ❑ 80 EMPTY IR 1 PRODUCT O iC MDGRADEUNLEADED ❑ 5 JET FUEL E] 8 M85 METHANOL ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN I❑��2 WASTE 2 LEADED ❑ 99 OTHER(DESCRIBE IN ITEM D.BELOW) D. IF IRA)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S.p 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 ,,❑II----II��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 9 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM 8 1001% METHANOL COMPATIBLE W/FRP (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER C.INTERIOR ❑ 1 RUBBER LINED ❑y 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING LINING OR ❑ 5 GLASS LINING lYl 6 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 10D% METHANOL? YES— NO-A D.EXTERIOR F-] 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC CORROSION 91 NONE 5 UNKNOWN ❑ 99 OTHER 9 PROTECTION F7s CATHODIC PROTECTION ❑ SPILL CONTAINMENT INSTALLED(Y R) O ERFILL PREVENT( OUIPMENT INSER CONTALED AINM E.SPILL AND OVERFILL,BSC. DROP TUBE YES_ NO YEAR TRIKER PLATE VES_ NO DISPENSER CONTAINMENT VES_ NO IV.PIPING INFORMATION CIRCLE A IFASOVEGROUNDOR 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 U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL A U 2- DOUBLE WALL A U 3 LINED TRENCH Am 95 UNKNOWN A U 99 OTHER C. MATERIAL AND A&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 B 100% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION U 95 UNKNOWN A U 99 OTHER 1 MELHANICAL LINE LEAN 2 UNE nGMNE55 ❑3 CCNtINUWa INTEPE1111AL ❑4 ELECTRONIC UNE ❑5 AUTDMAnC MMP 99 OTHER D. LEAK DETECTION ❑ CEiECTCR ❑ MUNnEl CO NU S =oETECTCR SHUTDDWN V.TANK TANK LEAK DETECTION ❑ 1 VISUAL CHECK - ❑ 2 MANUALRECONCINVENTORY ❑ 3 LIATIONMONOITORING ❑ 4 GAUL AUTOMATIC TANK F-15 GROMON ND WATER ❑6 ANNUAGTANK ❑ 7 CONTINUOUS INTERSTITIAL ❑ 8 SIR ❑ 9 WEETANLY MANTESTING UAL ❑10 Y TANK 95 UNKNOWN ❑ 99 OTHER MONITORING NG K 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 INERT MATERIAL? THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT TANK OWNER'S NAME (PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY# 1O TANK# D/ STATE 04 Lff 5D '1 q $w �i 0 -1 Tffn 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 PILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE U -'RGROUND STORAGE TANK REGULATIONS FORM 8 (6.95) ✓ ,) �'