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• STATE OF CALIFORNIA • STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B "� µ COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLO ED ON ITE ONE REM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED I DBA OR FACILITY NAME WHERE TANK IS INSTALLED: �-yVt/cl 5 LI QU O(Z5 b 1. TANK DESCRIPTION , COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A OWNER'S TANK I.D.f �� B. MANUFACTURED BY: C. DATE INSTALLED(MO/DAY/YEAR) / D. TANK CAPACITY IN GALLONS: II.TANK CONTENTS IFA-1 IS MARKED.COMPLETE ITEM C. A. �I MOTOR VEHICLE FUEL ❑ d OIL B. C. ❑may 1e REGULAR UNLEADED ❑ 3 t ❑ 6 AVIATION GAS ❑ 2 PETROLEUM ❑ BO EMPTY i PRODUCT 1�1b PREMIUM UNLEADED ❑ d ❑ 7 METHANOL ❑ 1C MIDGRADE UNLEADED ❑ 5 L ❑ 8 M65 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN 2 WASTE 2 LEADED ❑ 99ESCRIBE INREMO.BELOYqD. IF(A1)IS NOT MARKED. ENTER NAME OFSUBSTANCE STORED C.A.S. III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A,8,AND C,AND ALL THAT APPLIES IN BOX D AND A. TYPE OF I DOUBLE WALL im 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 ❑ I BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ,�4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP (PNmery Te k) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER C.INTERIOR ❑ I RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING LINING OR ❑ 5 GLASS LINING I�K 6 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 10096 METHANOL? YES NO— D.EXTERIOR ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC CORROSION PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER E SPILL AND OVERFILL,BLD. SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL P EVENTION EQUIPMENT INSTALLED(YEAR) DROP TUBE YESjir— NO_ STRIKER PLATE VES NO_ DISPENSER CONTAINMENT YES X NO_ IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U I SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION A U I SINGLE WALL A @ 2 DOUBLE WALL A U 3 UNED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND A U 1 BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)ACU)4 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL W/COATING A U 8 I00% 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 DETECTION MELHWCAL UNE cev ❑2 NNE IIGNTNE59 T�7 3 CIXRWNWS INIERSi11LLL ❑d ELECfRONIG UNE 'SXS AIIfGM411L PUMP O OTHER LETECfOR iE511NG �C�.f MONiORMG LEAK OEIELiOR �Y sxuroowx99 V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 MANUAL RECONCILIATION MONITORING ❑ 3 VADOZE MOONIITORING GAUGINGC TANK ❑5 MON UNKNOWN g9 GROND WATER ❑6 TESTNGTANK 7 CONTINUOUS MONITORING INTERSTITIAL ❑ 8 SIR ❑ 9 WEEKLY MANUAL E::]10 MONTHLY TANK g5 TANKGAUGING TESTING ❑ ❑ OTHER VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) I/,A 1.ESTIMATED DATE LAST USED(MO/DAY/YR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH ---+ SUBSTANCE REMAINING GALLONS INERT MATERIAL? -*E6'❑ NO❑ THIS FORM HAS BEEN COMPLETED UNDER PE TY OF P JURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT TANK OWNER'S NAME (PRINTED A SIGNATURE)/y)I I may- DATE ''7 1,I LOCAL AGENCY USE ONLY THE STATE I. . BER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY# L7 TANK# OD STATE I.D.4 m a I 8 (o O d PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE � y 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 INSTkLATIO4S. HIS FORM FORM B (6.95)SHOULD BE ACCOMPANIED BY A PLOT PIVLE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THEIRGROUND STORAGE TANK REGULATIONS L 8'b-�i1