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'eaoua�ea 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 ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 4W5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CL S ONE REM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE TXT 8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: 5OX3 t I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A. OWNERS TANK I.D.# B. MANUFACTURED BY: C. DATE INSTALLED(MO/DAYNEAR) 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. ❑ 1a REGULAR UNLEADED ❑ 3 DIESEL E] 6 AVIATION GAS 2 PETROLEUM ❑ 80 EMPTY ❑ 1 PRODUCT ❑ ib PREMIUM UNLEADED ❑ 4 GASAHOL ❑ 7 METHANOL ❑ 1c MIDGRADE UNLEADED ❑ 5 JETFUEL ❑ 8 M85 ❑ 3 CHEMICALPRODUCT ❑ 95 UNKNOWN 2 WASTE ❑ 2 LEADED ❑ 99 OTHER(DESCRIBE IN TfEMD.BELOM D. IF(A1)IS NOT MARKED, ENTER NAME OFSUBSTANCE STORED W 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 ❑ 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 5 INTERNAL BLADDER SYSTEM ❑ 95 UNKNOWN SYSTEM 2 SINGLE WALL ❑ 4 SINGLE WALL IN A VAULT ❑ 99 OTHER S. TANK X�1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ B 100% METHANOL COMPATIBLE W/FRP (Pl'ImaTy Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER C.INTERIOR ❑ 1 RUBBER LINED 1❑ 2 ALKYD LINING E] 3 EPDXY LINING ❑ 4 PHENOLIC LINING LINING OR ❑ 5 GLASS LINING IJCI 8 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 1001/6 METHANOL? YES_ NOX D.EXTERIOR ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC CORROSION 91 NONE F]95 UNKNOWN ❑ 99 OTHER PROTECTION ❑ 5 CATHODIC PROTECTION Ur E SPILL AND OVERFILL,6TC. SPILL CONTAINMENT INSTALLED Y OVERFILL PREVENTI N UIPMENT INSTALLED(YEAR) lyri DROPTUBE 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 U 1 SUCTION A U 2 PRESSURE A&)3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION Aa��UTT��1 SINGLE WALL A U 2- DOUBLE WALL A U 3 UNED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND A(p1 BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A U 4 FIBERGLASS PIPE CORROSION A 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 1 MECHW M LINE UJAK 2 UNE TIGHTNESS 3 CONTINUW9 INTVSi 4 ELECTRONIC LINE ❑5 Mff0WTIC PUMP 99 OTHER .L_ D. LEAK DETECTION ❑ �CTCR ❑ TESTING ❑ MONITORING ❑ LW9ElECTOR SHUTowx V.TANK LEAK DETECTION E-1 1 VISUAL CHECK E:] 2 RREECONCILIATIONORV ❑ 3 MONITORING E::] 4 GAUGINGIC TANK ❑5 GROUND MONITORING ANNUAL TANK ❑ 6 TESTING ❑ 7 CONTINUOU INTERSTITIAL E:] 8 SIR ❑ 9 WEETANKLY MANUAL ❑10 MOTESTINGHLY TANK ❑ 95 UNKNOWN ❑99 OTHER MITORIN VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE W-PLACE) 1.ESTIMATED DATE LAST USED(MO/DAYNFI) 2.ESTIMATED OUANTITY OF 3.WAS TANK RULED WITH YES ❑ NO _ SUBSTANCE REMAINING GALLONS INERT MATERIAL? /////��'�� THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT TANK OWNER'S NAME DATE (PRINTED 6 SIGNATURE) LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW c- O COUNTY# JURISDICTION# FACILITY# TANK# STATE I.D.# m 7Ame PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT IR ATE Q 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 A SHOULDBEACCOMPANIE�Y�PLOT P ILE THIS FORM WITH THE LOCA�G�CYIMPLEMENTING THE l�9�UN�ORA�T�RE��NS I""FORM B (6-951 UU c