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• STATE OF CALIFORNIA a STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION 7 PERMANENTLY CLO ONE ITEM F-12 INTERIM PERMIT O 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE 6 TANK REMOVED I O4 DBA OR FACILITY NAME WHERE TANK IS INSTALLED: �Ll'rril UyF7,V ��',L V y,•;. {� �a 3 ( S I. TANK DESCRIPTION COMPLETE ALL ITEMS— SPECIFY IF UNKNOWN A OWNER'S TANK I.D.R Lt B. MANUFACTURED BY: U C. DATE INSTALLED(MOiDAV/VEAR) a. D. TANK CAPACITY IN GALLONS: II.TANK CONTENTS IFA-1 IS MARKED,COMPLETE ITEM C. V A 1 MOTOR VEHICLE FUEL ❑ 4 OIL g, C la REGULAR UNLEADED ❑ 3 DIESEL ❑ 6 AVIATION GAS ❑ 2 PETROLEUM O 80 EMPTY ❑ 1 PRODUCT ❑ 1b PREMIUM UNLEADED ❑ 4 GASAHOL ❑ 7 METHANOL ❑ 3 CHEMICALPRODUCT O 95 UNKNOWN ❑ 2 WASTE ❑ 1C MDGRADE UNLEADED ❑ 5 JETFUEL ❑ 8 MBS ❑ 2 LEADED ❑ 99 OTHER(DESCRIBE IN ITEM D.BELONG D. IF(Al)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A S.R 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 ❑ i DOUBLE WALL O 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 E,2 I BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP (PHmwy TNnk) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER C.INTERIOR ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY UNING ❑ 4 PHENOLIC LINING LINING OR ❑ 5 GLASS LINING 6 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER COATING IS UNING MATERIAL COMPATIBLE WITH 100% METHANOL] YES_ NO_ D.EXTERIOR F-11 POLYETHYLENE WRAP O 2 COATING ❑ 3 VINYL WRAP O 4 FIBERGLASS REINFORCED PLASTIC CORROSION RgOS1 PROTECTION ❑ 5 CA THODICPROTECTION ® 91 NONE 95 UNKNOWN ❑ 99 OTHER E.SPILL AND OVERFILL,9N:. SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) DROP TUBE VES 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 Al)1 SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND Af 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 U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION ❑1 MECJ N TAL UNE UE ❑2 UK Tw9Tr M ❑3 cnNTNU=IKIER31111AL ❑4 ELE= N UNE 5 AMOI ATIC MW L OESECTOR TE9Ta1a II MTp IbAK 9ETECiOR ❑ SHUIOOWM ❑ 99 OTHER V.TANK LEAK DETECTION ❑ S VISUAL CHECK ❑ 2 RECONCILIATIONUAL ORY ❑ 3 MONIITORING OZE ❑ 4 GAUGING AUTOMATIC TANK ❑5 GROUND MONITORING TER ❑ e TESTING ❑ 7 MONITORING NUOUS INTERSTITIAL ❑ 6 SIR ❑ 9 WEEKLY MANUAL ❑ 10 MONTHLY TANK ❑ 95 UNKNOWN 99 OTHER TANK GAUGING TESTING ❑ VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE N-PUCE) 1.ESTIMATED DATE LAST USE (MO AY R)— 2.ESTIMATED OUANTITY OF 3.WAS TANK FILLED WITH R-�I IL,VI, S SUBSTANCE REMAINING GALLONS INERT MATERIAL YES ❑ NOIU THIS FORM HAS BE N C MPLETED UNDER PENALTY F PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS UE AND CORRECT TANKI3NYIER'S NAME n n DATE 11 LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW ✓/ COUNTY N JURISDICTION M FACILITY N TANK M r�L STATE I.D.# m = I I L{ , o PERMITNUMBER PERMIT APPROVEDBY/DATE PERMIT EXPIRATION DATE I r.l'I �r 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 PULE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE U GROUND STORAGETANK REGULATIONS �FORM B (695) 3