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�1 raraoy - cew•cc .. STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD +�� UNDERGROUND STORAGE TANK PERMIT APPLICATION-FORM B t COMPLETE A SEPARATE FORM FOR 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 ❑ 6 TEMPORARY TANK CLOSURE ❑ B TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: � v.S � .3-.5 � T 1. TANK DESCRIPTION COMPLETE ALL ITEMS– SPECIFY IF UNKNOWN A OWNER'S TANK I.D.• `fl !.t,; �/r- 77. B. MANUFACTURED BY: vC. GATE INSTALLED(MOAJAY/YEAR) D. TANK CAPACITY IN GALLONS: II TANK CONTENTS IF A-1 IS MARKED,COMPLETE ITEM C. /e REGULW UNLEADED 3 DIESEL ❑ 6 AVIATION GAS A ❑ 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C. /0 PREMIUM UNLEADED 4 GASAHOL ❑ ? METHANOL ❑ 2 PETROLEUM ❑ BO EMPTY ❑ 1 PRODUCT O lc MoBWE UNLEADED O 5 JET FUEL EDB M65 ED CHEMICAL PRODUCT 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED ❑ 99 OTHER IDFSCRBE N ITEM D.BELCH D. IF(At)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED TNEC>L C.A S.F: 111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A B.AND C.AND ALL THAT APPUES IN BOX D AND E A TYPE OF ❑ 1 DOUBLE WALL O 3 SINGLE WALL MRH EXTERIOR LINER ❑ 5 INTERNAL BLADDER SYSTEM ❑ 95 UNKNOWN SYSTEM ? 2 SINGLE WALL ❑ 4 SINGLE WALL M A VAULT ❑ 99 OTHER H. TANK OQ`1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEELCLAD.W/FISERGLASSREINFORCEDPLASTIC MATERIAL. ❑ 5 CONCRETE ❑ 6 .POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ B 100%METHANOL COMPATIBLE WIFRP (PTMmy T-k) ❑ B BRONZE ❑ 10 GALVANRED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER C.INTERIOR ❑ 1 RUBBER UNED O 2 ALKYD UNING ❑ 3 EPDXY LINING ❑ 4 PHENOUC LINING LINING OR ❑ 5 GLASS LINING 6 UNLINED ❑ 95 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 CORROSION 1 NONE ❑95 UNKNOWN ❑ 99 OTHER PROTECTION ❑ 5 CATHODIC PROTECTION SPILLCONTAINMENT INSTALLED(PEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) E SPILL AND OVERFILL,Btr- DROP TUBE YES_ NO Q STRIKER PLATE YES__ NO 4:f� DISPENSER CONTAINMENT YES— NO IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND,BOTH IF APPUCABLE A SYSTEM TYPE A40 1 SUCRON A U 2 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLEPIPING =OTHER B. CONSTRUCTION A 1 SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN G MATERIAL AND A® 1 BARE STEEL A U 2 STAINLESS STEEL A U 3 POLWINYL CHLORIDE(PVC)A U 4 FIBERGLASCORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEELW/COATING A U B 100% METPROTECTION A U B GALVAN® STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A AI 99 OTHERD. LEAK DETECTION1 WCHMIlTA1 LNE LEAK 2 LNE TIfaTIE55 3 CQTNUUIS NTFRSTIML 4 BECIWMC M[ s AVf01MTK RAP oElEcraB tFSTN9 Morrtwax9 ITAK oDErTaR 9NTOT.M1 V.TANK LEAK DETECTION 2 MANUAL UATIONINVENTORY ❑3 MVADOZE ONITORING ❑ 4 AUTOMATIC C TANK ❑6 GROUNDMONITO (WATER ❑6 TESTANNING❑ 1 VISUAL CHECK ❑ RECONCILIATION H MONITOR MANUAL 10 MONTHLY Tlis ANK UNKNOWN E:399 OTHER ❑ 7 MONITORI G INTERSTITIAL ❑ 6 SIR ❑ TANK GAUGING ❑ TESTING VL TANK CLOSURE INFORMATION(PERMANENT CLOSURE NI-PLACE) L ESTIMATED DATE LAST US (MO/DAY/YR) 2.ESTIMATED OUANRTY OF 3.WAS TANK FILLED WITH YES ❑ NO� SUBSTANCEREMAINING U'VC GALLONS INERTMATERIAL7 THIS FORM HAS BEEN COMPLETED UNDER PENAL7Y OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT TANK OWNERS NAME/)�j{ - F DATE ryRNIFD4 SIGiUTMF) /. '1 ��✓ �a Mil,/ (� l� __ UI' LOCAL AGENCY USE ONLY TH STATE LD.NUMBIER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY F JURISDICTION F FACILITY F TAN _. STATE LD:# -_ - m PERMIT NUMBER – PERMIT APPROVED BYIDATE PERMIT EXPIRATION DATE THIS FDIW MUSTSHOULD BE ACCOMPANIED BY A PLOT PLAN.FILE THIS FORM WITH THE-FORM A.UNLESS A CURRENT LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORBEEN FILED. FORM C MUST BE AGE ETANKFOR REGULATIONSINSTALLATIONS.THIS FORM FORMS (695)