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STATE OF CALIFORNIA . �`. STATE WATER RESOURCES CONTROL BOARD y�m�, e UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B is COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION 7 PERMANENTLY C ON ONE ITEM F__12 INTERIM PERMIT ❑ 4 AMENDED PERMIT [:] 6 TEMPORARY TANK CLOSURE 8 TANK REMOVE OBA OR FACILITY NAME WHERE TANK IS INSTALLED: Wc)c)dq/Xqthlppn I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A OWNER'S TANK I.D.# Uk B. MANUFACTURED BY: uk C. DATE INSTALLED(MOIDAYNEAR) Ilk D. TANK CAPACITY IN GALLONS: 900 II.TANK CONTENTS IF A-1 IS MARKED,COMPLETE ITEM C. A M 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C. to REGULAR UNLEADED a 3 DIESEL ❑ 6 AVIATION GAS ❑ 2 PETROLEUM ❑ SO EMPTY I PRODUCT ❑ ib PREMIUM UNLEADED o 4 GASAHOL ❑ 7 METHANOL ❑ le MIDGRADE UNLEADED ❑ 5 JET FUEL 8 M85 ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ® 2 LEADED ❑ 99 OTHER(DESCRIBE IN ITEM D.BELOW) D. IF(A1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A S.#: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A S.AND C.AND ALL THAT APPLIES IN BOX D AND E A. TYPE OF F-1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 5 INTERNAL BLADDER SYSTEM ❑ 95 UNKNOWN SYSTEM IJ 2 SINGLE WALL ❑ 4 SINGLE WALL IN A VAULT ❑ 99 OTHER S. TANK U I BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ B 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 ® 6 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL7 YES_ NO— D.EXTERIOR ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC CORROSION ® 91 NONE O 95 UNKNOWN ❑ 99 OTHER PROTECTION E] 5 CATHODIC PROTECTION SPILLCONTAINMENTINSTALLE EAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) E SPILL AND OVERFILL,BIC. DROP TUBE YES_ NO STRIKER PLATE YES_ NO__X_ 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 N OTHER B. CONSTRUCTION A O 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 7 STEEL W/COATING A U 8 100% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A Q 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION [:]I i M:LKWKAL UNI IFAN ❑2 UNE 11GIRNE53 ❑3 CGYnM MEAS E BE WC UK [:]5 AmGIMTC PNP E] 99 GTHER 9E1EL iE511N0 M MRIIG LEU CEIECTOR 9MDOYM V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK El2 MANUAL ECONCILIATIONO� ❑ 3 MONIITORING VAO ❑ 4 AUTOMATIROUND GAUGING C TANK ❑ 5 MON MONITORING F76 ANNUALTESTING ❑ T CONTINUOUSMONITORING INTERSTITIAL ❑ 8 SIR ❑ 9 YWENK GA GING [:]10 TESTNGY TANK ® g5 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) 1.ESTIMATED DATE LAST USED(MOIOAYNR) 2.ESTIMATED OUANTTY OF 3.WAS TANK FILLED WITH YES ❑ NO L_ Uk SUBSTANCE REMAINING Q GALLONS IN MATERIAL? THIS FORM HAS BEEN COMPL E NDEJI PFNAL OF RJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT TANK OWNERS NAME _ DATE (PRINTED A SIGNATUP 2/18/97 LOCAL AGENCY USE ONLY TH ATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY#9 4 $ TANK# U STATE I.Dl m 0 (, r, a G( gyp] _ 1 PERMIT NUMBER PERMIT APPROVED BYIDATE PERMIT EXPIRATION DATE THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPUCA�ON-FORMA,UNLESS A CURRENT FORMA HASBEENFILED. FORM C MUST BE COMPLETED FOR INSTALLATIONS.THISFORM SHOULD BE ACCOMPANIED BY A PLOT P•FLE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THGROUND STORAGE TANK REGULATIONS FORMS (6-95) r�'C1