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0uw ' STATE OF CALIFORNIA .P�'':9"• X01 STATE WATER RESOURCES CONTROL BOARD 3 + UNDERGROUND STORAGE TANK PERMIT APPLICATION -FORM B •�•t,f OR++'� 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 REM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT F<�6 TEMPORARY TANK CLOSURE ❑ 11 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: (',�(� K f>Tp(2 MAZgeFT /Z I. TANK DESCRIPTION COMPLETE ALL ITEMS— SPECIFY IF UNKNOWN A. OWNER'S TANK I.D.# ZS?> B. MANUFACTURED BY: g C. DATE INSTALLED(MO/DAYNEAR) In— 1118 S D. TANK CAPACITY IN GALLONS: g Doc) Ii.TANK CONTENTS IF A-1 IS MARKED,COMPLETE ITEM C. p� 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C. ❑ 1a REGULAR UNLEADED 3 DIESEL ❑ 6 AVIATION GAS 'iT 1b PREMIUM UNLEADED 4 GASAHOL ❑ 7 METHANOL F__] 2 PETROLEUM E::] 80 EMPTY 0_1 PRODUCT tc MIDGRADE UNLEADED ❑ 5 JET FUEL E:] 8 M85 ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED ❑ 99 OTHER(DESCRIBE IN ITEM D.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 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 K-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 Di�f6 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 1009% METHANOL? YES NO— D.EXTERIOR ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC CORROSION PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE 95 UNKNOWN ❑ 99 OTHER E.SPILL AND OVERFILL @TC. SPILL CONTAINME STALLED(YEAR) ^• OVERF LLL�'REVENTION EQUIPMENT INSTALLED(YEAR) + 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 A2 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTIONU 1 SINGLE WALL !r DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND U 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 GALVANIZED STEEL A U 10 CATHODE PROTECTION A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION 1 MECHANICAL UNE LEAK 2 UNE TIGHTNESS 3 CONTINUOUS INTERSTITIAL 4 ELECTRONIC UNE 5 AUTOMATIC PUMP DETECTOR ❑ TESTING MONITORING ❑ LEAK DETECTOR SHUTDOWN ❑ 99 OTHER V.TANK LEAK DETECTION VISUAL CHECK ❑ 2 MANUAL RECONCILIATIONORY ❑ 3 MONITORING 4 AUTOMATGAUGING IC TANK E] 5 GROUND MONITORING TER ❑ 6 ANNUALTESTING FiVI 7 CONTINUOUS MON TOR NG INTERSTITIAL ❑ 8 SIR E] 9 WEEK LY MANUAL ❑10 MST HLY TANK E::] 95 UNKNOWN E] 99 OTHER VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) 1.ESTIMATED DATE LAST USED(MO/DAY/YR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH 11A- SUBSTANCE REMAINING GALLONS INERT MATERIAL THIS FORM HAS BEEN COMPLETED UNDERpPENATY OF JURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT TANK OWNER'S NAME DATE (PRINTED&SIGNATURE) MIKE LIQ I LOCAL AGENCY USE ONLY THE STATE I.D. UMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY# TANK# STATE I.D.4 m J7_ ,�/T PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE Lj�L THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATI N-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. FORM MUST BE COMPLETED INSTALLATION4.THIS FORM SHOULD BE ACCOMPANIED BY A PLOT PLAjW THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UIIVROUND STORAGE TANK REGULATIONS FORM B (6-95)