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STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD l'? UNDERGROUND STORAGE TANK PERMIT APPLICATION -FORM B �� =� w . COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED ON SITE ONE REM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT J ❑ 6 TEMPORARY TANK CLOSURE 8 TANK REMOVED O DBA OR FACILITY NAME WHERE TANK IS INSTALLED: 1 r G e h # -501 ZU I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A OWNERS TANK I.0.0 WjZot) _007 B. MANUFACTURED BY: Ll nknown C. DATE INSTALLED(MLYDAY/YEAR) unknOion D. TANK CAPACITY IN GALLONS: ID 1 wV113 II.TANK CONTENTS IF A-1 IS MARKED,COMPLETE ITEM C. A W 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C. ❑ 1R REGULAR UNLEADED ❑ 3 DIESEL ❑ 6 AVIATION GAS ❑ 2 PETROLEUM ❑ SO EMPTY 1 PRODUCT ® /b PREMIUM UNLEADED ❑ 4 GASAHOL ❑ 7 METHANOL ❑ 3 CHEMICALPRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED UNLEADED ❑ 5 JET FUEL ❑ 8 MSS ❑ 2 LEADED ❑ 99 OTHER(DESCRIBE W REM 0.BELO`A) D. IF(Al)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A S.R 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 W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 6 100% METHANOL COMPATIBLE W/FRP (Primary Tank) ❑ 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 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 PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE �95 UNKNOWN ❑ 99 OTHER NT I E.SPILL AND OVERFILL,etc. SPILL CTAINMENSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) DROP TUBE YES NO_ STRIKER PLATE YES_ NO-DL- DISPENSER CONTAINMENT YES NO-92f— IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION AD PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION A SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED 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)A U 4 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL WI COATING A U 8 100% METHANOL COMPATIBLE W/FRP PROTECTION A&9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION bZ1 uEarmrx uxE 1PAIc 2 ME TRum S 3 CO IAXU6 RITERai1R4 4 ELECTRONIC ME 5 AGrGMATIC RuuP OEIECTOR ® TESTMa MONITORING ❑ EFN(GTEMM ❑ 9NIGOWN ❑ 99 OTHER V.TANK LEAK DETECTION �( 1 VISUAL CHECK 2 MANUAL CONCIUATONO� ❑ 3 MAONNIITORING ❑ 4 GAUGING MONITORING TANK E]5 GROUND MON TORINGTER F-1 TANK 6 TESTNANNUALG ❑ 7 MONITORING INTERSTITIAL ❑ 6 SIR ❑ 9 TANK GAUGING ❑10 TESTING TANK ❑ 95 UNKNOWN ❑99 OTHER VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PUCE) I.ESTIMATED DATE LAST USED(MO/DAY/YR) 2 ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES ❑ NO SUBSTANCE REMAINING GALLONS INERT MATERIAL? THIS FORM HAS BEEN COMPLETED UND R PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT TANK OWNERS NAME --T-DATE RENTEDR 610 T}1RE1 ean} -for T� IC6_o k} &/Z3/-17 LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY M JURISDICTION R FACILITY R I TANK R STATE I.Dl m PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICY '-FORM A,UNLESS A CURRENT FORMA HAS BEEN FILED. FOP- -MUST BE COMPLETED FOR INSTALLATIONS.THIS FORM .?Fj SHOULD BE ACCOMPANIED BY A PLOT PLA,.,.E THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE U _,GROUND STORAGE TANK REGULATIONS FORM B (6-95)