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• PEsouact rs STATE OF CALIFORNIA • ` wP Oi STATE WATER RESOURCES CONTROL BOARD ; UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B .. C1l IIOR H.� COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ONSITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE 7,�8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: F L A04 E 0 QV Q P,5 (t-�c . I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN j A OWNER'S TANK I.D.S r_1" Z, B. MANUFACTURED BY: UNI<.rvOl v+"' II C. DATE INSTALLED(MO/DAYNEAR) U/J KAjovj D. TANK CAPACITY IN GALLONS: 10 o o D II.TANK CONTENTS IF A-1 IS MARKED,COMPLETE ITEM C. q 1 MOTOR VEHICLE FUEL ❑ 4 OIL B, C ❑_to REGULAR UNLEADED ❑ 3 DIESEL ❑ 6 AVIATION GAS 2 PETROLEUM BO EMPTY 1 PRODUCT ib PREMIUM UNLEADED ❑ 4 GASAHOL ❑ 7 METHANOL ❑ 1c MIDGRADE UNLEADED ❑ 5 JET FUEL ❑ 8 M85 ❑ 3 CHEMICAL PRODUCT E] 95 UNKNOWN E] 2 WASTE El2 LEADED ❑ 99 OTHER(DESCRIBE IN ITEM D.BELOW) 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 :R�L 2 SINGLE WALL ❑ 4 SINGLE WALL IN A VAULT ❑ 99 OTHER B. TANK biU 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 100% METHANOL? YES— NO— D.EXTERIOR ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3-VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC CORROSION PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE 95 UNKNOWN ❑ 99 OTHER SPILL CONTAINMENT INSTALLED(YEAR) OVERFILI-PREVENTION EQUIPMENT INSTALLED(YEAR) E.SPILL AND OVERFILL,@TC. DROP TUBE YES NO STRIKER PLATE YES NO DISPENSER CONTAINMENT YES IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U i SUCTION A•-`U e2 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION A°U; 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.!t 1 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 U 1 MECHANICAL UNE LEAK [2 LINE TIGHTNESS 3 CONTINUOUS INTERSTITIAL 0 4 ELECTRONIC LINE ❑5 AUTOMATIC PUMP ❑ 99 OTHER DETECTOR TESTING MONITORING LEAK DETECTOR SHUTDOWN V.TANK LEAK DETECTION ANNUAL El 1 VISUAL CHECK El2 MANUAL INVENTECONCILATIONORY ❑ 3 MONITORING VADOZE ❑ 4 AUTOMATGAUGNGIC TANK E:]5 MONTORINGROUND WATER E:] 6 TESTINGTANK ❑ 7 MONITORING CONTINUOUSINTERSTITIAL ❑ 8 SIR ❑ 9 TANK GAUGINGAL E:] 10 MESTINGY TANK ff95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) 1.ESTIMATED DATE LAST USED(MO/DAY/YVK R) 2 SUBSTANCE UANTITY OF GALLONS 3.WASTANK FILLED NERT MATERIAL? YES ❑ NO': mootgcl� _ THIS FORM HAS BEEN COMPLETED UNDER P ALTY O RJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT TANK OWNER'S NAME DAT (PRINTED b SIGNATURE) 14A I ii e IL65 ,x,11 LOCAL AGENCY USE 7ONLY THE'STATE . .NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY# TANK# G STATE LD:# m � I 1 1 � Z 'c7 ;//3 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 0 FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THjfERGROUND STORAGE TANK REGULATIONS FORM B (6-95)