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i ' STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD s4 g UNDERGROUND STORAGE TANK PERMIT APPLICATION -FORM B COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTL ED O ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE 8 TANK RE V DBA OR FACILITY NAME WHERE TANK IS INSTALLED: . L C7vrti,R I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A OWNER'S TANK 1.D.It B. MANUFACTURED BY: C. DATE INSTALLED(MO/DAYNEAR) V D. TANK CAPACITY IN GALLONS: II.TANK CONTENTS IF A-1 IS MARKED,COMPLETE ITEM C. A. ❑ 1 MOTOR VEHICLE FUEL 50 14 OIL 8. to REGULAR UNLEADED ❑ 6 AVIATION GAS C. ❑ ❑ 3 DIESEL ❑ 2 PETROLEUM ❑ 80 EMPTY ❑ 1 PRODUCT ❑ 1b PREMIUM UNLEADED ❑ 4 GASAHOL ❑ 7 METHANOL El E UNLEADED ❑ 5 JET FUEL F-] 8 M85 ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN 2 E ❑ 99 OTHER(DESCRIBE IN ITEM D.BELOW) D. IF(A1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STO ED C.A S.M: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX AND OX 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 FXJ 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 ❑ 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 1001/6 METHANOL? YES_ NO— D.EXTERIOR ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC CORROSION PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE [24.95 UNKNOWN ❑ 99 OTHER E SPILL AND OVERFILLSPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) + , DROP TUBE YES NO X STRIKER PLATE YES NO X 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 GRAVITY A U 4 FLEXIBLE PIPING A U 99-.OTHER B. CONSTRUCTION Ao 1 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 i 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 > GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION ❑1 MECHANICAL LINE LEAK ❑2 LINE TIGHTNESS ❑3 CONTINUOUS INTERSTmAL4 ELECTRONIC LINE s AUTOMATIC PUMP ING DETECTOR TESTING MONITORE:] LEAK DETECTOR ❑ SHUTDOWN ❑ 99 OTHER V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 MANUAL RECONCILIATION IN ENTORY F-13 VADOZE ❑ 4 GAUGING C TANK E]5 GROUND WATER r---16 ANNUATESTINGTANK ❑ 7 MONITORING NUOUS INTERSTITIAL ❑ 8 SIR ❑ 9%EKLY GAUGANG� ❑10 MESNTHLY TANK 95 UNKNOWN ❑99 OTHER VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) 1.ESTIMATED DATE LAST USED(MO/DAY/YR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED 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 Lar�IIyjy` DATE (PRINTED N:SIGNATURE) f� /Y LOCAL AGENCY USE ONLY 4t:STATE I.D. UMBE IS COMPOSED�,.THE FOUR NUMBERS BELOW COUNTY N JURISDICTION M FACILITY N 003q-14 TANK k N9O,j STATE LDSm FTTI ® q g 9 Q/ 5 t � EPERMITNUMBER 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 PLAN. FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS FORMS (6-95) 0(//J C I- (,& Z�i�149