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STATE OF CALIFORNIA ec + STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B > , 1 COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT DCI 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ONSITE ONE REM ❑ 2 INTERIM PERMIT E] 4 AMENDED PERMIT /�❑--� TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: E. 0 I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A OWNER'S TANK I.D.# rJ A B. MANUFACTURED BY: v'j/c�jOb./'.7 C. DATE INSTALLED(MOIDAV/YEAR) V kN O�� D. TANK CAPACITY IN GALLONS: S� II.TANK CONTENTS IF A-1 IS MARKED,COMPLETE ITEM C. ❑ 1 MOTOR VEHICLE FUEL [VT 4 OIL B. C. ❑ to REGULAR UNLEADED ❑ 3 DIESEL ❑ 6 AVIATION GAS A ❑ 2 PETROLEUM ❑ 80 EMPTY ❑ 1 PRODUCT ❑ 10 PREMIUM UNLEADED ❑ 4 GASAHOL ❑ 7 METHANOL ❑ le MIDGRADE UNLEADED ❑ 5 JET FUEL ❑ 8 M85 ❑ 3 CHEMICALPRODUCT ❑ 85 UNKNOWN � WASTE ❑ 2 LEADED ❑ 99 OTHER(DESCRIBE IN ITEM D.BELOW) D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED wf{STE OI 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 ❑ 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 5 INTERNAL BLADDER SYSTEM ❑ 95 UNKNOWN A. TYPE OF ❑ SYSTEM �2 SINGLE WALL ❑ 4 SINGLE WALL IN A VAULT 99 OTHER 1 BARE STEEL ❑ 2 STAINLESS STEEL [E3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B. TANK + F-1 MATERIAL ❑ 5 CONCRETE ❑ 8 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ B 100% METHANOL COMPATIBLE W/FRP (Primary Tank) 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING C.INTERIOR LINING OR ❑ 5 GLASS LINING ❑ 8 UNLINED E] 95 UNKNOWN El99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO_ - D.EXTERIOR ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING E] 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC CORROSION �/91 NONE E:195 UNKNOWN E:] 99 OTHER PROTECTION ❑ 5 CATHODIC PROTECTION SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) - E.SPILL AND OVERFILL,etc. DROP TUBE YESNO__ STRIKER PLATE VES_ NO_ DISPENSER CONTAINMENT VES_ NO IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE U SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION A / SINGLE WALL A U 2DOUBLE 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 4 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL W/COATING A U B 100% METHANOL COMPATIBLE WIFRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION ❑1 MELXANIGLL UNE UAIL UNE BGNTNESS 3 CONTINUOUS IIaERSTmAL ❑4 JIECm C UNE O 5 AVo"nC PUMP gg OTHER pEUVOR TESTING Md MJOUS LFAK OE1ECi0R SHUMM V.TANK LEAK DETECTION 1 VISUAL CHECK I-1 2 RANUAL TANK ECONCIUATIONORV ❑ 3 VADOZEMONITORING ❑ 4 AUTOMATGAUGING MONITORING TANK ❑ 5 GROUND MONTORINGTER ❑ 6 ANNUALTESTING ❑ 7 MONITORING INTERSTITIAL ❑ 6 SIR ❑ 9 WEETANLY GAUGINGAL ❑10 TESTINGNTHLY TANK ❑ 85 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) 3.WAS TANK FILLED WITH YES ❑ NO /`� 1.ESTIMATED DATE LAST USED(MOIDAYNR) 2.ESTIMATED QUANTITY OF 5r I0� 7� SUBSTANCE REMAINING o GALLONS INERT MATERIAL? THIS FORM HAS BEEN COMP ETED UNDER PEATY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT DATE TANK°OWNEWS'TL11ME L. . (PRINTED4SIGNATURE) E."o"6Vj ON{f RV CT.uN CAR4T 1✓' Al�.#deoi�N - I " / LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY It JURISDICTION# FACILITY# TANK# STATE I.D.# 77q � U 3 PERMIT NUMBER PERMIT APPROVED BYIDATE PERMI 'PI 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 HIS FORM SHOULD BE ACCOMPANIED BY A PLOT PI THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THI ROUNDTO�EGGNK REGUL�ON� �S-117 FORM B (6-95) G