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STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM B 4ACCOMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. �% J MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ONSITE ONE REM ❑ 2 INTERIM PERMIT ❑ d AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE B TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A OWNER'S TANK 1.D.a na B. MANUFACTURED BY: unknown C. DATE INSTALLED(MO/DAYNEAR) unknown D. TANK CAPACITY IN GALLONS: 1 , 000 gal II.TANK CONTENTS IF A 1 IS MARKED,COMPLETE ITEM C. A Ej�k1 MOTOR VEHICLE FUEL ❑ d OIL B. C.❑ 0 la REGULAR UNLEADED I�I 3 DIESEL ❑ 6 AVIATION GAS 2 PETROLEUM El 00 EMPTY 1 PRODUCT lb PREMIUM UNLEADED E0 d GASAHOL ❑ 7 METHANOL ❑ 1C MIDGRADE UNLEADED5 JET FUEL ❑ B M85 ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE KX 2 LEADED g 99 OTHER(DESCRIBE IN ITEM D.BELOW) D. IF(A.I)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 A. TYPE OF - ❑��1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 5 INTERNAL BLADDER SYSTEM El 95 UNKNOWN Iuc SYSTEM 1 z 2 SINGLE WALL ❑ < SINGLE WALL IN A VAULT ❑ 99 OTHER B. TANK I BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ a STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP (Primary Tank) ❑ 9 BRONZE ❑ E:]10 GALVANIZED STEEL 95 UNKNOWN ❑ 99 OTHER C.INTERIOR ❑ I RUBBER UNED El 2 ALKYD LINING ❑ 3 EPDXY UNNG ❑ d PHENOLIC LINING LINING OR ❑ 5 GLASS LINING X6� 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 ❑ d FIBERGLASS REINFORCED PLASTIC CORROSION PROTECTION ❑ 5 CATHODIC PROTECTION [:] 91 NONE XIS 1 95 UNKNOWN E] 89 OTHER E.SPILL AND OVERFILL,61D. SPILL CONTAINMENT INSTALLED(YEAR) nye-OVERFILL PREVENTION EOUIPMENT 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 xx SUCTION A U 2 PRESSURE A U 3 GRAVITY A U A FLEXIBLEPIPING A U 99 OTHER B. CONSTRUCTION A 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 A FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL W/COATING A U A 100% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION p 23eS UNKNOWN A U 99 OTHER 0. LEAK DETECTION ❑1 MECN !M LNE LFAF 2 LINE TIGNINESS 3 CS WTERSTm d FLEMMC UNE 5 AWOI. "C MWXnCTOR ❑ CW111MN TESIIG I Imm ❑ L ❑UE XE CTDR 5NIROOWN ❑ 99 OTHER V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 RECONCILIATIONMANUALINVENTMOND❑ 3 VAOZEMON ORING ❑ d GAUGING AUTOMATIC TANK ❑5 MONITORING GROUND TER ❑ TANK 6 TESTING ❑ 7 CONMON INUOUC�S INTERSTITIAL ❑ 8 SIR ❑ 9 TANK MANUAL ❑ 10 MONTHLY TANK 95 UNKNOWN El 99 OTHEORINR TESTING VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) 1.ESTIMATED DATE LAST USED(MO/DAY/YR) 2.ESTIMATED OUANTITY OF 00 3.WAS TANK FILLED WITH YES E::] NO� nknown ] SUBSTANCE REMAINING GALLONS NERT MATERIAL THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO44-E BEST OF 4Y KNOWL DGE, IS TRUE AND CORRECT TANK OWNER'S NAM E / — DATE IPRINTEDd 61GNATVRET .�'� � �� LOCAL AGENCY USE ONLY THE ATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS ELOW COUNTY a JURISDICTION M FACILITY M 0(pal(,�j TANK M 0`� STATE I.D.# 1611 15141.ZIA5 1 S a 3 PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATIRM A,UNLESS A CURRENT FORM A HAS BEEN FILED. FORM T RE COMPLETED FOR INSTALLATIONS.THIS FORM SHOULD BE ACCOMPANIED BY A PLOT PLAN. HIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDE ..DUND STORAGE TANK REGULATIONS FORMA IA.951 (A R/a,7 lua