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- euircaa STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION -FORM B COMPLETE A.SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY Q 1 NEW PERMIT Q 3 RENEWAL PERMIT Q 5 CHANGE OF,INFORMATION Q PERMANENTLY CLOSED ON SITE ONE ITEM ❑ 2 INTERIM PERMIT Q 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED. 1. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN : A OWNERS TANK L D.♦ —[Y,L._ B, MANUFACTURED BY: N��i`�ou�1 G DATE.INSTALLED(MOIDAYIYEAR) D.TAMC CAPACITY IN GALLONS: II.TANK CONTENTS IF A-1 1S MARKED,COMPLETE ITEM C. 4 1 MOTOR VEHICLE FUEL Q 4 01L BG �^^ m O 3 DIESEL a 6 AVIATICNI GAS ❑ 2 PETROLEUM ❑ 80 EMPTY !� ! I PR �7 C)DUCT 1b PREmm UNLEADEDQ 4 GASAHOL ❑ 7 METHANOL J} ❑ 1c MIDGAADE UNLEADED 0 5 JET FUEL 0 8 MBS ❑ 3 CHEMICAL PRODUCT 0 95 UNKNONM' ❑ 2 WASTE ❑ 2 LEADED Q 99 0THER(DESCRIBE w TTFJm D.smom D. IF(A.1)IS NOT MARKED. ENTER NAME OF SUBSTANCE STORED , C`AA S.j. Ill. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.M AND C.AND ALL THAT APPLIES IN BOX D AND E A. TYPE OF 1 DOUBLE WALL ❑ 3 SINGLE WAIL WITH EXTERIOR LINER Q 5 INTERNAL BLADDER SYSTEM Q 95 UNKNOWN SYSTEM L]Cf Z SINGLE WALL Q SINGLE WALT. M A VAULT ❑ 99 OTHER B. TANK Ef 1 BARE STEEL ❑ 2 STAINLESS STEEL Q 3 FIBERGLASS Q 4 STEEL CLAD WI FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM Q 8 100% METHANOL COMPATIBLE WIFRP M"MM ❑ 9 BRONZE 0 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER C.INTERIOR ❑ 1 RUBBER LINED Q ALKYD LINING Q 3 EPDXY LINING. ❑ 4 PHENOLIC LINING LINING OR : Q 5 GLASS LINING UNLINED ❑ �9s WKNOWN ❑ 99 OTHER. COATING I IS LINING MATERIAL COMPATIBLE WITH 100'G METHANOL? YES No D.EXTERIOR ❑ 1 POLYETHYLENE WRAP Q 2 COATING Q 3 INYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC CORROSION PROTECTION 0 5 CATHODIC PROTECTION 91 NONE 95 UNKNOWN .. ❑ 99 OTHER SPILL CONTAINMENT 1 ALLED(YEAR) VER P 1M SPILL EQUIPMENT INSTAL LED(YEAR) E SPILL AND OVERFILL,¢tC DROP TUBE 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 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTIONU SINGLE WALL A U 2 DOUBLE(WALL A U 3 :LINED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND A T] BARE STEEL A U 2 STMNLESS STETS A U 3 POLYVINYL CHLORIDE(PVL)A U 4 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U e CONCRETE °A U 7w/COATING A U B 70o%METHANOL OOMPATIBLE WIFRP PROTECTION A U GALVANIZED STEEL U 10 I,CATHODICPROTECTION U UNKNOWN A U 99 OTHER - , 0. LEAK DETECTION M 1111EcmFt - 21 nWnCZ.❑ 3 uomenNUOLIS o r11ER5TIIlAL 4 u€ O 5 ww [D99 OM4Ut _ V.TANK LEAK DETECTION _ ❑ 1 VISUAL CHECK vs RCONNCILIAAL TIOON NTOW Q aMMNII'TOORING ;,.ZFE Q 4GAUGING-TIC TANK ❑s ,LGAOONNTrrORlNG�R. 8.TWNNGANNUALTANK ❑ 7. CONTINLKri151NTEASTITIAL SLR ❑ 9 WEEKLY MANUAL ❑.10 MONTHLY TANK":❑ 95 UNKNOWN' Q 99 OTHER MONITORING _ _ ..-. TANK GAUGING -TesmNa VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE R r r.ACE} ]. MATED DATE LJIS"T USEQ(MOIOAY/YR} 2 ESTIMATED QUANTITY OF 3 WAS TANK FIE LED WITH '1 •C� SUBSTANCE REMAINING GALLONS INERT MATERIAL.? ATERIAL 7 No t. THIS FORM HAS BEEN COMPLETED UNDER PENALTYW PE UR I A TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT TANK OWNER'S NAME .L LOCAL AGENCY USE ONLY THE STATE LO.r�Ms>�i sEfa DF FOUR NUMBERSLaw COUNTY i. _JURISDICTION 0 . FACILITY i TANK i STATE I.D. T_F-I PERMIT NUMBER 7 _ PERMT EXPIRATION D_ TE ,�RE _ THIS FORM MUST BE ACCOMPANIED BY A PERMTT APPLr"'ION•FORA A.UNLESS A CURRENT FORM A.HAS BETA FILED.Ff"H C MUST 13E COMPLETED FOR SWALLATIOUL-THUS FOR& SHOULD BE ACCOMPANIED BY A PLOT F LE THIS FORM WITH THE LOCAL AGENCY WPLEYENTING TH GROUND STORAGETANK REGULATIONS FORM B (6.95) h