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• • STATE OF CALIFORNIA • �� eCO+* STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B 3 COMPLETE A SEPARATE FORM FOR •EACH TANK SYSTEM. � MARK ONLY l NEW PERMIT ❑ FO 3 RENEWAL PERMIT y.�l 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ONSITE ONE REM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ TEMPORARY TANK CLOSURE ❑ //8 TANK REMOVED I DBA OR FACILITY NAME WHERE TANK IS INSTALLED: Ll. E. I I .�„_ Td Til-vim I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A OWNER'S TANK I.O.# !"1 MACTURED BY: V tJRNpWr�A C. DATE INSTALLED(MO/DAY/YEAR) u nj F N'3w D. TANK CAPACITY IN GALLONS: , It.TANK CONTENTS IF A-1 IS MARKED,COMPLETE ITEM C. A ❑ 1 MOTOR VEHICLE FUEL �4 OIL 8. C. ❑ la REGULAR UNLEADED ❑ 3 DIESEL ❑ 6 AVIATION GAS r7 2 PETROLEUM ❑ BO EMPTY ❑ 1 PRODUCT ❑ 1E PREMNM UNLEADED ❑ 4 GASAHOL ❑ 7 METHANOL ❑ Ic 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(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED wA:'T E O i C.A S.#: 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 F❑ I DOUBLE WALL F73 SINGLE WALL WITH EXTERIOR LINER ❑ 5 INTERNAL BLADDER SYSTEM ❑ 95 UNKNOWN SYSTEM L=7 2 SINGLE WALL ❑ 4 SINGLE WALL IN A VAULT ❑ 99 OTHER B. TANK , ❑ 1 BARE STEEL ❑ 2 STAINLESS STEEL EU?3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE O 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL 95 UNKNOWN ❑ 99 OTHER C.INTERIOR ❑ 1 RUBBER LINED ❑ 2 ALKYD UNING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING LINING OR ❑ 5 GLASS LINING ❑ 6 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 10096 METHANOL YES_ NO— D.EXTERIOR O—D.EXTERIOR ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC CORROSION —y PROTECTION ❑ 5 CATHODIC PROTECTION -I 91 NONE —] 95 UNKNOWN ❑ 99 OTHER � E.SPILL AND OVERFILL,BSC. 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 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 4 FILEXIBLEPIPING 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 / BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A V4 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL W/COATING A U 8 1001/6 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 [:]' MECKkNIM UNE LEAK UNE MWNEW 3 CONnNUWS INTERSTInAL 4 ELECn1ONIC UNE 5 AUfONARC PUMP DETECTOR TESTING ❑ MONTCMG ❑ LEAN OETECiOR ❑ SHU= 99 OTHER V.TTA( ANK LEAK DETECTION u 1 VISUAL CHECK ❑ 2 NUAL RECONCILIATIONMANUAL MONITORING ❑ 3 VADOZE MONIITORING El AUTOMATGAUGINGIC TANK ❑ 5 GROUND MONITORINGTER E:] 6 TESTINGTANK ❑ 7 CONMON INUOU INTERSTITIAL ❑ 8 SIR ❑ 9 WEEK LY MANUAL ❑10 MO T HLY TANK ❑ 95 UNKNOWN ❑99 OTHER ORINNG VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) 1.ESTIMATED DATE LAST USED(MOIDAYNFI) 2.ESTIMATED QUANTITY OF A �.rO 3.WAS TANK FILLED WITH (9 �- SUBSTANCE REMAINING J GALLONS INERT MATERIAL 7 YES ❑ NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT TANWRTTMEWS'fTAME ten. Ly DATE (PRINTED d SIGNATURE) a/6 LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION If FACILITY# i`l TANK# STATE I.D:# FT)Fql = I I I I I I PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT'EXPI 10NfMTE-- 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 PLA E THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE U 106&GROUND STORAGE TANK REGULATIONS FORM B (6-95) i_ / ,f N /' ,rq FOR0034&R7