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,r ..- STATE OF CALIFORNIA NEL/ `wU.«s Oot STATE WATER RESOURCES CONTROL BOARD o UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B i COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ON SITE ONE ITEM ❑ 2'INTERIM PERMIT O 4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED n DBA OR FACILITY NAME WHERE TANK IS INSTALLED: Iis4 Q G 7 I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A OWNER'S TANK I.D.p B. MANUFACTURED BY: C. DATE INSTALLED(MO/DAY/YEAR) D. TANK CAPACITY IN GALLONS: II.TANK t CONTENTS IFA-1 IS MARKED,COMPLETE ITEM C. 1/ryN1 MOTOR VEHICLE FUEL ❑ 4 OIL a.�j( C, ❑ 1a REGULAR UNLEADED 3 DIESEL ❑ 6 AVIATION GAS A '❑ 2 PETROLEUM ❑ 80 EMPTY 7V 1 PRODUCT ❑ 1b PREMIUM UNLEADED 4 GASAHOL ❑ 7 METHANOL f� ❑ 10 MIDGRADE UNIEADEDn(=-� 5 JET FUEL ❑ 8 M85 E::] 3 CHEMICAL PRODUCT E] 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED U 99 OTHER(DESCRIBE IN ITEM D.BELOY!) D. IF(AI)IS NOT MARKED. ENTER NAME OF SUBSTANCE STORED C.A S.p: 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 B. TANK 1 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 (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER C.INTERIOR ❑ I 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_ NOyA D.EXTERIOR ❑ I POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC CORROSION PROTECTION ❑ 5 CATHODIC PROTECTION X 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER E.SPILL AND OVERFILL,etc. SPILL CONTAINMENT STALLED(YEAR) OVERFILL PREVENT) N EQUIPMENT INSTALLED(YEAR) DROP TUBE YES NO STRIKERPLATE YES_ NO DISPENSER CONTAINMENT YES NO IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND,BOTH IF APPU CABLE A. SYSTEM TYPE I SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION A Q 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 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 EjI MECHANICAL ZINE IFA)( 2 UNE TIOWNESS 3 CONTINUOUS INTERSTmAL 4 ELECTRONIC LINE 5 AIIrOMATG PUMP 9 OTHER MTECTOR O TESTING a MONITORING O LW OEIECTOR O SHUTOµ V.TANK LEAK DETECTION ❑ ANNUAL 1 VISUAL CHECK 2 RECO CILIATIONNUAL INVENTORY E::] 3 MAONNIITORING ZE ❑ 4 AUTOMATGAUGINGIC TANK ❑5 MONTORINGTERGROUND 6 TESTINGTANK ❑ 7 MONITORCONTINUOUS E:] 8 SIR E::] 9 WEEKLY MANUAL ❑10 MOTESNTHLY TANK E] 95 UNKNOWN ❑ 99 OTHER NG VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PUCE) 1.ESTIMATED DATE LAST USED(MO/DAY/YR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES ❑ NO EDSUBSTANCE 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 a SIGNATURE) LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY p, JURISDICTION p r-�---FACILITY-p�-��10t TANK pma STATE I.D:# L� L l � PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE 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 PL` FILE THIS FORM*41101WITH;THE LOCAL AGENCY IMPLEMENTING THE P"^ERGROUND STORAGE TANK REGULATIONS E��(. FORM B (6-95) 3- �+L 6 —� ? / ' 4