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S • P�Souq t9 C STATE OF CALIFORNIA °tir STATE WATER RESOURCES CONTROL BOARD i UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B W a COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY;�� 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ON ONE ITEM 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT Ilk" 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED Il DBA OR FACILITY NAME WHERE TANK IS INSTALLED: ZZ,, �� _-) " 9 i I. I F►IV1% Ur-OlIo lr I IUIV COMPLETE ALL ITEMS - SPECIFY IF UNKNUVVN A OWNER'S TANK I. D. # B. �� r 2 PETROLEUM ❑ 80 EMPTY B. MANUFACTURED BY: 1b PREMIUM UNLEADED ❑ 4 GASAHOL ❑ 7 METHANOL ❑ 1c MIDGRADE UNLEADED ❑ 5 JET FUEL ❑ 8 M85 C. DATE INSTALLED (MO/DAY/YEAR) ❑ 2 WASTE ❑ 2 LEADED ❑ 99 OTHER (DESCRIBE IN ITEM D. BELONG D. IF (A.1) IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C. A. S. # D. TANK CAPACITY IN GALLONS: zoo J II. TANK CONTENTS IF A-1 IS MARKED, COMPLETE ITEM C. A 1 MOTOR VEHICLE FUEL 4 OIL B. C. to REGULAR UNLEADED ❑ 3 DIESEL D 6 AVIATION GAS r 2 PETROLEUM ❑ 80 EMPTY 1 PRODUCT 1b PREMIUM UNLEADED ❑ 4 GASAHOL ❑ 7 METHANOL ❑ 1c MIDGRADE UNLEADED ❑ 5 JET FUEL ❑ 8 M85 ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED ❑ 99 OTHER (DESCRIBE IN ITEM D. BELONG D. IF (A.1) IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED 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 B. TANK ❑ 1 BARE STEEL ❑ 2 STAINLESS STEEL I, 3 FIBERGLASS �❑ E]4 STEEL CLAD W/ FIBERGLASS REINFORCED PLASTIC MATERIAL F—]5 CONCRETE ❑ 6 POLYVINYL CHLORIDE 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP (Primary Tank) ❑ g 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 X6 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES NO— DETECTOR D. EXTERIOR Ell 1 POLYETHYLENE WRAP ❑ 2 COATING El 3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC CORROSION ❑ 5 CATHODIC PROTECTION a 91 NONE ❑ 95 UNKNOWN 99 OTHER PROTECTION SPILL CONTAINMENT INSTALLED (YEAR) r OVERVENTION EQUIPMENT INSTALLED (YEAR) FI PRE E. SPILL AND OVERFILL, etc. DROP TUBE YES NO TRIKER PLATE YES NO DISPENSER CONTAINMENT Y S NO IV, PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND, BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION A -d' 2 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL A 2 DOUBLE 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 U 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 1 MECHANICAL UNE LEAK ❑ 2 UNE TIGHTNESS 3 CONTINUOUS INTERSTITIAL 4 ELECTRONIC LINE E 5 AUTOMATIC PUMP ❑ 99 OTHER DETECTOR TESTING MONITORING LEAK DETECTOR SHUTDOWN V. TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ INTERSTITIAL ❑ 7 MONITORCONTINUOUS 3 VADOZE MONIITORING ❑ 4 AUTOMATGAUGING IC TANK ❑ 5 GROUND MONITORING TER 2 MANUAL RECONCILIATION MONITORING [:j 8 SIR El WEEK LY MANUAL ❑ 10 MONTESTHLY TANK ❑ g5 UNKNOWN TANK ❑ 6 ANNUALTESTING ❑ 99 OTHER VI. TANK CLOSURE INFORMATION (PERMANENT CLOSURE IN-PLACE) 1. ESTIMATED DjT LA D (MO/DAY/YR) 2. ESTIMATED QUANTITY OF 3. WAS TANK FILLED WITH YES [:]NO ❑ x\//14 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 9 U COUNTY # JURISDICTION # FACILITY # TANK # STATE I.D:# FAY1111G101�- 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,,PLnOT PI °ILE THFORM WITH THE LOCAL AGENCY IMPLE NTING THE I IMnERGROUND STORAGE TANK REGULATIONS FORM B (6-95) T.