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STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B i COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY t NEW PERMIT ❑ 3 RENEWAL PERMIT CHANGE OF INFORMATION PERMANENTLY CLOSED ON SITE ONE REM 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT TEMPORARY TANK CLOSURE //8 TANK REMOVED ©9 OBA OR FACILITY NAME WHERE TANK IS INSTALLED: E. SAO J I. TANK DESCRIPTION COMPLETE ALL ITEMS— SPECIFY IF UNKNOWN A OWNER'S TANK I.D.# t- A B. MANUFACTURED BY: ✓ . wl� C. DATE INSTALLED(MO/DAYNEAR) V-j N, D. TANK CAPACITY IN GALLONS: II.TANK CONTENTS IF A-1 IS MARKED,COMPLETE ITEM C. A ❑ 1 MOTOR VEHICLE FUEL 4 OIL B. C. ❑ la REGULAR UNLEADED ❑ 3 DIESEL ❑ 6 AVIATION GAS ❑ 2 PETROLEUM ❑ 80 EMPTY ❑ 1 PRODUCT ❑ lb PREMIUM UNLEADED ❑ 4 GASAHOL ❑ 7 METHANOL N ❑ 10 MIDGRADE UNLEADED ❑ 5 JET FUEL ❑ 8 M65 ❑ 3 CHEMICALPRODUCT 095 UNKNOWN [ ` WASTE ❑ 2 LEADED ❑ 99 OTNER(OESCRIBEINITEMO.BELO'M 0. IF(A.1)IS NOT MARKED, ENTER NAME OFSUBSTANCE STORED L�J,�STE O I C.A.S.#: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.8,AND C.AND ALL THAT APPLIES IN BOX D AND E A. TYPE OF F711 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 5 INTERNAL BLADDER SYSTEM ❑ 95 UNKNOWN SYSTEM FE 2 SINGLE WALL ❑ 4 SINGLE WALL IN A VAULT ❑ 99 OTHER B. TANK ❑ 1 BARE STEEL ❑ 2 STAINLESS STEEL [VJ3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE Ej 7 ALUMINUM 8 100°/6 METHANOL COMPATIBLE W/FRP (PrimaryTank) ❑ 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% METHANOL? YES_ NO— D.EXTERIOR ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC CORROSION ❑95 UNKNOWN ❑ 99 OTHER PROTECTION ❑ 5 CATHODIC PROTECTION 91 NONE SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) E.SPILL AND OVERFILL,6IC. DROP TUBE YE$_ NO_ STAIKER PLATE VES_ NO_ DISPENSER CONTAINMENT YES_ NO IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION A (U1 SINGLE WALL A U 2 DOUBLE WALL A U 3 UNED 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 W 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 E:]' MECNN m LME LFAIL UNE MWMESS [:]3 ODNnNUWS INTFASTmAL ❑4 ELMr;NIC UNE E:]5 A100-11t PUMP 99 OTHER DETECTOR TESTING NGNTORING [FAN OE1ECi0R S411TODWN V.TANK LEAK DETECTION 1 VISUAL CHECK ❑ 2 RECONCILATIONORV ❑ 3 MONIITORING OZE ❑ 4 AUTOMATGAUGNGIC TANK ❑5 GROUND MONITORING TESTING❑ 6 TESTINNUALGTANK ❑ 7 CONTINUOUS MON TORNG INTERSTITIAL ❑ B SIR ❑ 9 TANEK GAUGINGAL ❑10 TESTINGY TANK ❑ 95 UNKNOWN ❑ 99 OTHER Vi.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) 1.ESTIMATED DATE LAST USED(MO/DAYNR) 2.ESTIMATED QUANTITY OF 115 O � io- 7 S SUSSTANCE REMAINING GALLONS INERT MATERIAL? THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT SAE t, __ DATE (PRINTED&SIGNATURE) AM)7a pYLL w �dc2,c LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY# TANK#(� STATE I.D.# M U 3 S S o y b PERMIT NUMBER PERMIT APPROVED BY/DATE PERMI I THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICIAl�lION-FORM A,UNLESS A CURRENT FORMA HAS BEEN FILED. FORM C MUST BE COMPLETED FOR INSTALLATIONS. THIS FORM SHOULD BE ACCOMPANIED BY A PLOT PW THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE GROUND STORAGE TANK REGULATIONS FOR0071&M FORM 8 (6.95) (f�