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STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B 1 COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM, O 7 PERMANENTLY CLOSE SITE MARK ONLY ❑ 1 NEW PERMIT 3 RENEWAL PERMIT y/� 5 CHANGE OF INFORMATION ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT L�JI 8 TEMPORARY TANK CLOSURE n B TANK REMOVED / DBA OR FACILITY NAME WHERE TANK IS INSTALLED: q(A' rY I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN B. MANUFACTURED BY: A OWNER'S TANK I.D.N IAI C. DATE INSTALLED(MOIDAV/YEAR) UAIL D. TANK CAPACITY IN GALLONS: 2 II.TANK CONTENTS IFA-1 IS MARKED.COMPLETE ITEM C. to REGULAR UNLEADED 3 DIESEL ❑ 6 AVIATION GAS A 1 MOTOR VEHICLE FUEL ❑ 4 OIL S. C ❑ 1D PREMIUM UNLEADED 4 GASAHOL ❑ 7 METHANOL ❑ 2 PETROLEUM ❑ 80 EMPTY ❑ 1 PRODUCT ❑ 1c IADGRADE UNLEADED ❑ 5 JETFUEL ❑ 8 MBS ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED ❑ 99 OTHER(DESCRIBERN ITEMD.BELOW) D. IF(A1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S.N: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A B,AND C,AND ALL THAT APPLIES IN BOX D AND ❑ 1 DOUBLE WALL F-13 SINGLE WALL WITH EXTERIOR LINER ❑ 5 INTERNAL BUDDER SYSTEM E] 95 UNKNOWN A. TYPE OF ❑ ❑ 99 OTHER SYSTEM 2 SINGLE WALL 4 SINGLE WALL IN A VAULT B. TANK J25 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CUD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE O 7 ALUMINUM ❑ B 10D% METHANOL COMPATIBLE W/FRP (PrimaryTank) ❑ 9 BRONZE O 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER C.INTERIOR ❑ 1 RUBBER LINED r❑ 2 ALKYD LINING 3 EPDXY LINING ❑ 4 PHENOLIC LINING LINING OR El GLASS LINING I o 6 UNLINED 95 UNKNOWN 99 OTHER COATING IS LINING MATERIAL COMPATIBU(VWTH 100% METHANOL? YES_ NO— D.EXTERIOR ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC CORROSION PROTECTION ❑ 6 CATHODIC PROTECTIONfVr 91 NONE ❑95 UNKNOWN ❑ 99 OTHER E.SPILL AND OVERFILL,INC. 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 IFAPPUCABLE A. SYSTEM TYPE A 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLEPIPING 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 A 1 BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A U 4 FIBERGLASS PIPE CORROSION A 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL W/COATING A U B 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 DETECTH)NTI 1Ecxvxx KE LEAK 2 MGHnass 3 c WUWS lt(M Tmu 4 E1Ec1RONN UNE5 AurouAnc RMP ❑1 U �iECIGB ❑ TESINp ❑ MCN10RM3 LEAK OETECi0N1 ❑ SNUIWWN ❑ 99 OTHER V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 RMANUAL IINVEO ORY ❑ 3 VAMONITORING LNG E] 4 AUTOMAGTIC TANK ❑5 GRN ND WATER ❑ 6 ANNUALTESNTANK AT1R❑ 7 MONI TORING ITORING INTERSTITIAL ❑ B SIR ❑ 9 WEETANK LY MGAUGANUAL ❑10 MEONTHLY TANK ❑ 96 UNKNOWN ❑ 99 OTHER STING VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) 1.E TED DATE LAST USED(MO/DAYIYR) 2.ESTIMATED QUANTITY OF /I414 3.WAS TANK FILLED WITH YES ❑ NO� l[_ SUBSTANCE REMAINING IAN•% GALLONS INERT MATERIAL? THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT TANK OWNER'S NAME DATE (PRMTED A SIGNATURE) ArML Dg.r„/ A_ JZ LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY p JURISDICTION p FACILITY N TANK N STATE I.D:# I I I q I q I�jjoL!5 PERMIT NUMBER PERMIT APPROVED BYIDATE 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 INSTALLATIONS.THIS FORM SHOULD BE ACCOMPANIED BY A PLOT PLA' '.E THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UV `GROUND STORAGE TANK REGULATIONS FORMS (6.95) 1 / .Of FOROBI4B117