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STATE OF CALIFORNIA i STATE WATER RESOURCES CONTROL BOARD 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 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: I. TANK DESCRIPTION COMPLETE ALL ITEMS, SPECIFY IF UNKNOWN - A. OWNERS TANK 1.D.• "? 1 B. MANUFACTURED BY: a /1! Tal r+ C. DATE INSTALLED(MOVDAY/YEAR) 14, D. TANK CAPACITY IN GALLONS: 10 0:1)0 II.TANK CONTENTS IF A-1 IS MARKED,COMPLETE ITEM C. A 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C. to REGULAR UNLEADED e 3 DIESEL 6AVIATION GAS 2 PETROLEUM 80 EMPTY 991 PRODUCT Ib PREMIUM UNLEADED4 GASAHOL ❑ 7 METHANOL tc MADE UNLEADED 5 JETFUEL 8 M85 ❑ 3'CHEMICAL PRODUCT ❑ 95 UNKNOWN ® 2 WASTE ® 2 LEADED 99 OTHER(DESCRIBE IN ITEM 0.BELOM 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 I DOUBLE WALL ® 3 SINGLE WALL WITH EXTERIOR LINER ❑ 5 INTERNAL MADDER SYSTEM ® 95 UWICWN 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 ❑ 8 100%METHANOL COMPATIBLE W/FRP (Pnmary 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 1009E METHANOL? YES_ NO— D.EXTERIOR ( 1 POLYETHYLENE WRAP ® 2 COATING CORROSION �t ® 3 VINYL WRAP ® A FIBERGLASS REINFORCED PLASTIC PROTECTION. ❑ 5 CATHODIC PROTECTION ❑ 91 NONE ❑95 UNKNOWN ❑ 99 OTHER E.SPILL AND OVERFILL,glg, ILL SPCONTAINMENT i STALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) _ DROP TUBE YES f. NO STRIKER PLATE YES wl- 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 2 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 U 1 BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL.CHLORIDETMA U 4 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL WI COATING A 8 100% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A OTHER"L r? D. LEAK DETECTION ®1 OMCTORcAL uwE tFJK ❑z TEsrea �3 art�smlu ®4 13E DMC OR ®s MRmATIC PUMP ❑99 OTHER NKMffrCRWG161K oE'iECTCR 9KRDOWN V.TANK LEAK DETEC11ON ❑ 1 VISUAL CHECK ❑ 2 MANUAL LLWTINVENTTORY ❑ 3 VADOZE 4 AUTOMATIC TANK ®5 GROUND WATER ®6 ANNUALTANK CONTINUMONITORING GAUGING MONITORING TESTING ® 7 MONITOROU��SINTERSTLTIAL ❑ 8 SIR ❑ 9 TWEEKLYUGINGAL ®10 MONTHLY TANK ® 95 UNKNOWN ❑99 OTHER STIN Vl.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN.PLAcE) LESTIMATED DATE LAST USED(MO/DAY/YR) 2.ESTIMATED QUANTITY OF 3 WAS TANK FILLED WITH YES ❑ NO GA SUBSTANCE REMAINING LLONS INERT MATERIAL? THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT TANK OWNERS NAME+�,v t .^/loTY%�V DATE (PRWTE06SIGNATURE) "Al 4T9 ''�- "� -Jim-�,�1/��'�'''� .✓ +/.Ml�.'/A�Cy -T'! �/ "A3 LOCAL AGENCY USE ONLY THE STATE LD.N v COMPOSED OF THE FOUR NUMBERS BELOW COUN # JURISDICTION? FACILITY# TANK# STATE LD:# TY m FTT� I I 1 11 1❑ PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION- RM A,UNLESS A CURRENT FORM A HAS BEEN FILED. FORM Cdow BE COMPLETED FOR INSTALLATIONS.THIS FORM SHOULD BE ACCOMPANIED BY A PLOT PIAN FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDIW UNO STORAGE TANK REGULATIONS FORM B (6-95)