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0 0 STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. 60UwCt5 v s 0 Cil,/ON1.1♦ MARK ONLY ❑ / 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: 4'45a Z::', 14 fr' / Z. J j„w j ❑ 4 STEEL CLAD WI FIBERGLASS REINFORCED PLASTIC L TANK DESCRIPTION COMPLETE ALL ITEMS - SPECIFY IF UNKNOWN A. OWNER'S TANK 1. D, a B. MANUFACTURED BY: C to REGULAR UNLEADED ❑ 3 DIESEL ❑ 6 AVIATION GAS ib PREMIUM UNLEADED ❑ 4 GASAHOL ❑ 7 METHANOL C. DATE INSTALLED (MO/DAYJYEAR) D. TANK CAPACITY IN GALLONS: Ic MIDGRADE UNLEADED ❑ 5 JET FUEL ❑ 8 M85 11 TANK CONTENTS IF A.1 IS MARKED. COMPLETE ITEM C. 1 MOTOR VEHICLE FUEL 4 OIL A ❑❑ 80 EMPTY B. � 1 PRODUCT C to REGULAR UNLEADED ❑ 3 DIESEL ❑ 6 AVIATION GAS ib PREMIUM UNLEADED ❑ 4 GASAHOL ❑ 7 METHANOL ❑ 2 PETROLEUM ❑ A. TYPE OF SYSTEM Ic MIDGRADE UNLEADED ❑ 5 JET FUEL ❑ 8 M85 ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE 2 LEADED ❑ 99 OTHER (DESCRIBE IN ITEM 0. BELOVO 0. IF (A.1) IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C. A. S. a III TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A. B. AND C, AND ALL THAT APPLIES IN BOX D AND E I1/ DIDIAIi: INFnQAAATInN elori c A IF Aanvc PGnuNO OA U IF UNDERGROUND. BOTH IF APPLICABLE A. SYSTEM TYPE ❑ I DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 5 INTERNAL BLADDER SYSTEM 95 UNKNOWN IT A. TYPE OF SYSTEM ❑ 2 SINGLE WALL ❑ 4 SINGLE WALL IN A VAULT ❑ 99 OTHER A U 2 DOUBLE WALL A U ❑ 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD WI FIBERGLASS REINFORCED PLASTIC B. TANK MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 1001/6 METHANOL COMPATIBLE W/FRP (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL � 95 UNKNOWN ❑ 99 OTHER PROTECTION ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING77 - EPDXY LINING ❑ 4 PHENOLIC LINING C. INTERIOR LINING OR ❑ 5 GLASS LINING F-16 UNLINED 5 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 CORROSIONA E] PROTECTION ❑ 91 NONE 95 UNKNOWN ❑ 99 OTHER PROTECTION 5 CATHODIC I E. SPILL AND OVERFILL, E tC. SPILL CONTAINMENT INSTALLED (YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED (YEAR) DROP TUBE YES NO STRIKER PLATE YES NO DISPENSER CONTAINMENT YES NO I1/ DIDIAIi: INFnQAAATInN elori c A IF Aanvc PGnuNO OA U IF UNDERGROUND. BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING Q THER B. CONSTRUCTION A U T SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A ey5 UNKNOWN A U 99 OTHER C. MATERIAL AND A 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 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A (UNKNOWN A U 99 OTHER-, D. LEAK DETECTION ❑ 1 tAECWV 1CAL INE LEAK ❑ 2 UNE TIGHTNESS ❑ 3 CONTINUOUS INTERST(IU! ❑ 4 EtrOTNIC twE ❑ 5 AUTOMATIC PUMP s OTHER u - CEAK DETECTOR SHUTDOWN DETECTOR TESTING MOMTORINO V TANK i FAK nFTFCTION ❑ t VISUAL CHECK F]2 RMANUAL ECONCILIATION MONITORING ❑ 3 VADOZE ❑ 4 GAUGG AUTOMATIC TANK 5 , TORINGTER ❑ 6 ANNUAL ❑ 7 CONTINUOUS INTERSTITIAL ❑ 8 SIR ❑ 9 TANEKLY K LY MANUAL ❑ 10 MONTHLY TANK 95 UNKNOWN ❑ 99 OTHER NITORIN VI. TANK CLOSURE INFORMATION (PERMANENT CLOSURE IN-PLACE) 1. ESTIMATED DATE LAST US (MO AYNR) 2. ESTIMATED QUANTITY OF 3, WAS TANK FILLED WITH SUBSTANCE REMAINING GALLONS INERT MATERIAL ? YES F-] NO `1W THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT TANK OWNERS NAME DATE (PRINTED 6 SIGNATURE) Ar' A i AP_eLIP•V 1 ICC AKI1 V Tuc erATc 1 n Ail INCCo IC m uonem nF TNF Fn11R NUMBERS BELOW LV VAI. /9 V1{.1\VI VVV VI\YI IIIL JIl�iL l.w.•l�v.rarr.. ... ��.... ��. ...�-------------- COUNTY # JURISDICTION # FACILITY # TANK # STATE Wl [�R = I I Z,// ZA 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 INSTALLATIUNS. I MIb rvnm SHOULD BE ACCOMPANIED BY A PLOT PL ILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE' 9GROUND STORAGE TANK REGULATIONS FORM 8 (6.95) 'J