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STATE OF CALIFORNIA STATE*ATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION-FORM B COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. - EM LY M 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 4oe ry1•• ' ❑ 2 INTERIM PERMIT ❑ ❑ 5 CHANGE OF INFORMATION (� 4 AMENDED PERMIT ❑ 8 7EMPORp ly TANK CLOSURE ur�,1 7 PERMANENTLY CLOSED ON SITE ACILITY NAME WHERE TANK IS INSTALLED: 8 TANK REMOVED I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A OWNER'S TANK I.D.t L G DATE INSTALLED(MO/DAY/YEAR) /( /.5 B. MANUFACTURED BY: C' D. TANK CAPACITY IN GALLONS: II.TANK CONTENTS IF A-1 IS MARKED,COMPLETE ITEM C. A 1 MOTOR VEHICLE FUEL 4 OIL 2 PETROLEUM B' C. 1a REGULM UNLEADED 3 DIESEL ❑ B AVIATION GAS 80 EMPTY ❑ 1 PRODUCT ❑ 1E PREMMM UNLEADED 4 GASAHOL ❑ 7 METHANOL ❑ 3 CHEMICALPRODUCT ❑ 85 UNKNOWN 2 WASTE ❑ Ic MIDGRADE UNLEADED n 5 JET FUEL O B MBS ❑ 2 LEADED C. 99 OTHER D. IF i/l1)IS NOT MARI�D, ENTER NAME OF SUBSTANCE STORED 1 C.A S.#: (DESCRIBE IN ITEM D.BELOW) NIL TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A B,AND C.AND ALL THAT APPLIES IN BOX D AND E AI A. TYPE DP F71 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER L__] 5 INTERNAL BLAMER SY51EM _ 95 UNKNOWN SYSTEM 2 SINGLE WALL ❑ 4 SINGLE WALL IN A VAULT E::] 99 OTHER — S. TANK 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 8 POLYVINYL CHLORIDE ❑ 7 ALUMINUM 8 100% METHANOL COMPATIBLE W/FRP (FA�yT-k) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL 5Z795 UNKNOWN ❑ 99 OTHER C.INTERIOR ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY UNING ❑ 4 PHENOLIC LINING LINING OR ❑ 5 GLASS LINING ❑ 8 UNUNED Kf 95 UNKNOWN ❑ 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? VES— 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.BIC. 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 1 SUCTION A U 2 PRESSURE Agbb GRAVITY A U 4 FLEXIBLE PIPING A U W OTHER S. CONSTRUCTION A U 1 SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH UJ95 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 B CONCRETE A U7 S L W/COATING A U 8 111^ METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION U 95 UNKNOWN A U 99 OTHER 1 MECN M 111E IF.N! 2 lNE TIGN11E55 3 WH9MIW4 NiFA3TIfML 4 FIECRMMC UNE 5 AUTOWTIC PIM 99 OTHER 0. LEAK DETECTION ❑ ce1Ea� ❑ TE81R0 ❑ MONtaANO ❑ UAK oETEcraR ❑ sHuloovm ❑ V.TANK LEAK DETECTION 1 VISUAL CHECK ❑ 2 RECONCILIATIONORY ❑ 8 MONITORING ❑ 4 GAUGING AUTOMATIC TANK ❑8 MOONITORINGROUND WATER ❑8 TESTING WEEKLYNUAL ❑ 7 Co MON TORING INTERSTITIAL ❑ B SIR ❑ 9 TANKLGAUGING AL ❑ 10 MONTHLY TANK ❑ 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) 1.ESTIMATED DATE LAST 5 (M V R 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES ❑ NO� SUBSTANCE REMAINING GALLONS INERT MATERIAL? THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT TANK OWNERS NAME ` \ ATE / (PRINTED 4 SIDNATUREI 1 q p1 / f. ) _ 1,2_1v LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS C OSED OF THE FOUR NUMBERS BELOW COUNTY A JURISDICTION N FACILITY#00.941.3 TANK N QO STATE I.D:# m z 3 D Z 8 EPERMITBER PERMIT APPROVED BY/DATE 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 I ALLATIORS.THIS FORM SHOULD BE ACCOMPANIED BY A PLOT P RLE THIS FORM WITH THE LOCAL AGENCY PAPLEMENTING THF 'ERGROUND STORAGE TANK REGULATIONS FORM B (&95) `-' ~