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STATE OF CALIFORNIA c'. STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B , I COMPLETE A SEPARATE FORM FO EACH TANK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ONSITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT n 6 TEMPORARY TANK CLOSURE ID B TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: T' Q I. TANK DESCRIPTION COMPLETE ALL ITEMS— SPECIFY IF UNKNOWN A OWNERS TANK 1.D.# m14f, B. MANUFACTURED BY: Uu C. DATE INSTALLED(MO'DAYNEAR) Mue— D. TANK CAPACRY IN GALLONS: II.TANK CONTENTS IF A-1 IS MARKED,COMPLETE ITEM C. 1 MOTOR VEHICLE FUEL ❑ 4 OIL S. C. Ia REGULAR UNLEADED 3 DIESEL ❑ 8 AVIATION GAS A lb PREMIUM UNLEADED ❑ 4 GASAHOL ❑ 7 METHANOL ❑ 2 PETROLEUM ❑ 80 EMPTY ❑ i PRODUCT El Ic MIDGRADE UNLEADED ❑ 5 JET FUEL ❑ 8 M85 ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE Q 2 LEADED ❑ 99 OTHER ryESCflIBE IN ffFM D.BFLOYl) D. IF(A1)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 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 WT 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.INFERIOR ❑ I RUBBER LINED ❑�-�y 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING LINING OR F-15 GLASS LINING 1 7L 6 UNLINED E] 95 UNKNOWN ❑ 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES— NO— D.EXTERIOR ❑ 1 POLYETHYLENE WRAP O 2 COATING Q 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC CORROSION � PROTECTION [:j2 5 CATHODIC PROTECTION � 91 NONE ❑95 UNKNOWN ❑ 99 OTHER E SPILL AND OVERFILL,MC. 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 SUCTIN A U 2 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION Aul 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 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 COMMPPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER__Xff6>= D. LEAK DETECTION ❑1 Lacxuacu WE LEY( ❑2 INE 1NHIEESS F-13 CCIAMIWS NTERST ❑4 E3ECTRDND UNE ED 5 AUrOM m mw 99 OTHER OflECrOF TESLING Mp4T0RND TEM DETECTOR SNRWWX V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 gRECONCILIATIONAL ORY ❑ 3 MAONNIITORING ZE ❑ 4 GAUGING AUTOMATIC TANK ❑ 5 GROUND MONITORING F-1 ANNUALTANK 6 TESTING ❑ 7 MON TOR NPS G INTERSTITIAL ❑ 8 SIR ❑ 9 TANK L MANUAL ED 10 MONTHLY TANK ❑ 95 UNKNOWN ❑99 OTHER TESTING VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) 1.E t DATE LAST USED(MO/DAY/YR) 2.ESTIMATED GUANRTY OF `{ GALLONS 3 WAS TAN WAS WITH YES ❑ NO� SUBSTANCE REMAINING MATERIAL THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT TANK OWNER'S NAMEDATE/��f (PAINTED A SIGNATURE) AA04e fXy Cf41 XY LOCAL AGENCY USE ONLY THE STATE I.D.duMBER IS COMPOSED OF THE FOUR NUMBERS BELOW I COUNTY# JURISDICTION If FACILITY It TANK M STATE I.D.# © 111 a 19 1 /n/vZ� PERMIT NUMBER PERMIT APPROVED BYIDATE PERMIT EXPIRATION DATE THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICAT^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 PLOT PLA .E THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UE' `GROUND STORAGE TANK REGULATIONS FORM B (6.95) lw FORD034"T