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0 STATE OF CALIFORNIA .p o STATE WATER RESOURCES CONTROL BOARD 3 UNDERGROUND STORAGE TANK PERMIT APPLICATION -FORM B � 3 COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ON SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: C44u vo N t1— B140 I. TANK DESCRIPTION COMPLETE ALL ITEMS– SPECIFY IF UNKNOWN A OWNER'S TANK 1.D.# 2 I B. MANUFACTURED BY: Yr-- C. C. DATE INSTALLED(MO/DAYNEAR) I Gi Y7 D. TANK CAPACITY IN GALLONS: 151 II.TANK CONTENTS IF A-1 IS MARKED,COMPLETE ITEM C. A. 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C 1a REGULAR UNLEADED ❑ 3 DIESEL ❑ 6 AVIATION GAS F—] 2 PETROLEUM ❑ 80 EMPTY 1 PRODUCT lb PREMIUM UNLEADED ❑ 4 GASAHOL ❑ 7 METHANOL i 7" 1C MIDGRADE UNLEADED5 JETFUEL ❑ E::] B M85 ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 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 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 El8 100% METHANOL COMPATIBLEW/FRP (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER RUBBERLINEDF__] 2 ALKYD LINING C.INTERIOR ❑ 1 � 3 EPDXY LINING 4 PHENOLIC LINING ❑ LINING OR ❑ 5 GLASS LINING X 6 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 10D% METHANOL? YES— NO— D.EXTERIOR ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP CORROSION insi 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION 91 NONE ❑95 UNKNOWN ❑ 99 OTHER E.SPILL AND OVERFILL BtC. SPILL CONTAINMENT I TALLED(YEAR) OVERFILL P VENTION EQUIPMENT INSTALLED(YEAR) DROP TUBE YES NO ST IKER 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 2 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL 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)A0 4 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEELW/COATING A U 8 100% METHANOL COMPATIBLEW/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 LINE LEAK 2 LINE TIGHTNESS 3 CONTINUOUS INTERSTITIAL `�4 ELECTRONIC UNE 5 AUTOMATIC PUMP DETECTOR [:] TESTING MONITORING Lam• LEAK DETECTOR SHUTDOWN ❑ 99 OTHER V.TANK LEAK DET CTION 1 VISUAL CHECK 2 MANUAL% RECONCILIATION INVENTORY 3 VADOZE MONITORING 4 AUTOMATGAUGING IC TANK ❑5 GROUND MONITORING TER F76 ANNUALTESTING 7 CONTINUMONITOR U INTERSTITIAL [:] 8 SIR ❑ 9 WEEK LY MAN NUAL 10 MO TINLY TANK ❑ 95 UNKNOWN ❑99 OTHER VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) 0 ,& 1.ESTIMATED DATE LAST USED(MO/DAYNR) 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 P�,L (P RCt6 D&SIGN C NAME t4,5.0"E N� DATE (PRINTED 6 SIGNATURE) G �p�G LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY# TANK# OG C,� STATE I.D.1 D PERMIT NUMBER PERMIT APPROVED BYIDATE PERMIT EXPIRATION DATE I 0 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 PLALE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE U�GROUND STORAGE TANK REGULATIONS FORM B (6-95)