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STATE OF CALIFORNIA s STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION -FORM B COMPLETE A SEPARATE FORM FOWEACH TANK SYSTEM. MARK ONLY I NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMAN TLY CLOSED ONSITE ONE ITEM 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE e T REMOV L DBA OR FACILITY NAME WHERE TANK IS INSTALLED: I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A. OWNER'S TANK I.0.# f 1 fl'/f)44'7 -OT' I S. MANUFACTURED BY: 7 7� C. DATE INSTALLED(MMAY/YEAR) Ien- I 0. TANK CAPACITY IN GALLONS. S `"x-xD II.TANK CONTENTS IF A-1 IS MARKED.COMPLETE ITEM C. A 1 MOTOR VEHICLE FUEL El4 OIL B. C. to REIx'UTAR UNLEADED 3 OIESEL ❑ 6 AVIATION GAS ❑ 2 PETROLEUM ❑ 80 EMPTY t PRODUCT tb PREMIUM UNLEADED 4 GASAHOL ❑ 7 METHANOL to MK0ME UNLEADED 5 JET FUEL 8 M85 ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED 99 OTHER(DESCRIBE IN ITEM 0.BELOW) 0. 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 0 AND E A. TYPE OF 4 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR UNER ❑ 5 INTERNAL BLADDER SYSTEM ❑ 95 UNKNOWN SYSTEM ❑ 2 SINGLE WALL ❑ 4 SINGLE WALL W A VAULT ❑ 99 OTHER B. TANK ❑ 1 BARE STEEL ❑ 2 STAINLESS STEEL M 3 FIBERGLASS ❑ 4 STEEL CLAD W1 FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE J 6 POLYVINYL CHLARIOE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER C.INTERIOR ❑ I RUBBER LINED ❑ 2 ALKYD LINING ® 3 EPDXY LINING ❑ 4 PHENOUC LINING LINING OR ❑ 5 GLASS LINING 8 UNLINED 9S 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 C::] PROTECTION 5 CATHODIC PROTECTION ❑ 91 NONE ®95 UNKNOWN ❑ 99 OTHER E SPILL AND OVERFILL,etc SPILL CONTAINMENT INSTALLED(YEAR) 1 t OVERFILL PREVEN11ON EQUIPMENT INSTALLED(YEAR) I 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 02 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WAIL Al 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)AW4 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL WrCOATING 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 lo' **ww-L Lm L" ❑2 3 CMT==oasaasrttut ❑4 Oulu 5 vaw ❑99 OTMER V.TANK LEAK DETECTIONMANUALVADOZE ( ( ❑ ND 1 VISUAL CHECK 72 RECONCILIATIONO� ® 3 MONITORING (��s+ 4 GAUGINGAUTOMATIC TANK ❑5 MONITORINGWATER ®6 TE�NGTANK 7 MONITOR U INTERSTITIAL Cl8 SIR ® 9 WEEKLYTANK MANUAL 10 MONTHLY TANK ❑ 95 UNKNOWN ❑99 OTHER VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE i 1.ESTIMATED DATE LAST USED(MO(DAYNR) 2.ESTIMATED QUANTITY OFI 3.WAS TANK FILLED WITH YES F7 NO C:]SUBSTANCE REMAINING GALLONS! INERT MATERIAL 7 THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGF-IS TRUE AND CORRECT TANK OWNERS NAME , n DATE / ( a 51 Tt7Rq }, /J f d riff 1, LOCAL AGENC USE ONLY THE STATE I.D.NUMBER IS COM S TH OUR NUMBERS BELOW COUNTY# JURISOICTION# FACILITY# TANK STATE I.D:4Z3�o PERMIT NUMBERI PERMIT APPROVED SY/OATE I PERMIT EXPIRATION DATE THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPUU''—l)N-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. FORM C MUST BE COMPLETED FOR INSTALLATIONS.THIS FORM SHOULD BE ACCOMPANIED BY A PLO RLE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THfd,, 9GROUND STORAGE TANK REGULATIONS FORM B (6-95)