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STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD 5'0 UNDERGROUND STORAGE TANK PERMIT APPLICATION -FORM B � � :° ( COMPLETE A SEPARATE FORM M EACH TANK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5CHANGE OF INFORMATION Q 7 PERMANENTLY CLOSED ON SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT 8 TEMPORARY TANK CLOSURE 8 TANK REMOVED 43) DBA OR FACILITY NAME WHERE TANK IS INSTALLED: Newt k— I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A OWNER'S TANK I.D.♦ Ak' I B. MANUFACTURED BY: uu C. DATE INSTALLED(MO/DAYNEAR) uN,� D. TANK CAPACITY IN GALLONS: 'Z V✓V II.TANK CONTENTS IFA-1 IS MARKED,COMPLETE ITEM C. p Z 1 MOTOR VEHICLE FUEL ❑ 4 OIL ILC. 1e REGULAR UNLEAOm 3 DIESEL [j6 AVIATION GAS ❑ 2 PETROLEUM ❑ 80 EMPTY ❑ 1 PRODUCT ❑ ib PREMUM UNLEADED 4 GASAHOL ❑ 7 METHANOL E::] 1c MIDGRADE UNLEADED E::] 5 JET FUEL ❑ 8 MSS ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED ❑ 99 OTHER(DESCRIBE N TEIAD.BELOLYI D. IF(A1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A S.#: III. TANK CONSTRUCTION MARK ONE REM 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 UNER ❑ 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 ❑ B POLYVINYL CHLORIDE ❑ 7 ALUMINUM B 100% METHANOL COMPATIBLE W/FRP (Pr'natY T-10 ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER C.INTERIOR ❑ I RUBBER LINED ❑#y 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC UNING LINING OR ❑ 5 GLASS UNING Z{,6 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO— D.EXTERIOR ❑ 1 POLYETHYLENE WRAP O 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC CORROSION PROTECTION ❑ 5 CATHODIC PROTECTION 2T 91 NONE ❑95 UNKNOWN ❑ 99 OTHER E SPILL AND OVERFILL,eW. SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION 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 1 RUCTION A U 2 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION A 1 SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND U I 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% METHppp{NNN/oL C�OMyP-ATIOLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER/VENC D. LEAK DETECTION ❑I raCRMRcu BNE" ❑2 Ura TXwlras ❑3 w9IPMCU 11KI R!I m ❑4¢LCmoRN Bra ❑5 AU nC P W ❑ 99 oTHER oEl am TEmxG eCr4raNa LCNc oETEcrGR gMrwxH V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 MANUALINVENTRECONCILIATION MONITORING ❑ 3 MONITORING ED GAUGING AUTOMATICTANK ❑5 MOON TORING�R E:] ANNUALTANK 8 TESTING ❑ 7 MONITORING INTERSTITIAL ❑ 8 SIR ❑ 9 WEEN LpIMANUAL ❑ 10 M SNTHGTINY TANK ❑ 95 UNKNOWN ❑ 98 OTHER VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PUCE) 1.E jED DATE LAST USED(MO/DAY/YR) 2 SUBSTANCE REMAININGF << GALLONS 3 WAINERT MATERIAL TH YES ❑ NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT TANK OWNER'S NAMEA , -�.ty GAr DATE� (PRINTF])A SIGNANRE) LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW I COUNTY k JURISDICTION a FACILITY It TANK a STATE I.D.# PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE 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 PLA' .E THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UP `GROUND STORAGE TANK REGULATIONS FORMS (6-95) FOWN&RT