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STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM B r 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 ITEM ❑ 2 INTERIM PERMIT F-14 AMENDED PERMIT ❑ 8 TEMPORARY TANK CLOSURE 8 TANK REMOVED O DBA OR FACILITY NAME WHERE TANK IS INSTALLED:.205 �j, I. TANK DESCRIPTION COMPLETE ALL ITEMS— SPECIFY IF UNKNOWN A OWNERS TANK I.D.0 B. MANUFACTURED BY: C. DATE INSTALLED(MODAYNEAR) f♦ gEF D. TANK CAPACITY IN GALLONS: ^� , II.TANK CONTENTS IF A-1 IS MARKED,COMPLETE ITEM C. A 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C. 18 REGULAR UNLEADED ❑ 3 DIESEL ❑ 8 AVIATION GAS ❑ 2 PETROLEUM ❑ SO EMPTY ❑ 1 PRODUCT 1251 ib PREMIUM UNLEADED ❑ 4 GASAHOL ❑ 7 METHANOL Ic MIDGRADE UNLEADED E:] 5 JET FUEL ❑ 8 M85 ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN 2 WASTE E] 2 LEADED ❑ 99 OTHER(DESCRIBE IN REM D.BELOW) 0. IF(A.1)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 E A. TYPE OF 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 5 INTERNAL BLADDER SYSTEM ❑ 95 UNKNOWN SYSTEM 2 SINGLE WALL ❑ 4 SINGLE WALL IN A VAU�L-,T5 ❑ 99 OTHER B. TANK F-1I BARE STEEL [:] 2 STAINLESS STEEL IJL 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL E-15 CONCRETE ❑ 8 POLYVINYL CHLORIDE T❑] 7 ALUMINUM ❑ 8 100% 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 F-15 GLASS LINING E] 8 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 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 APPUCABLE A. SYSTEM TYPE AID 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL A 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 0 4 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U B CONCRETE A U 7 STEEL W/COATING A U 8 100% METHANOL COMPATIBLE W/FI9P PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTIONI M UNE UM2 ME TI39 $S W 3 Nu wrERsnnAL 4 EU:CIRIXNC Ura: 5 AUroNAPuns M ❑ pE MEC(ffm ❑ TESMAI Molt O lw LEAK O Crm ❑ SKIIrCOWN [:D 99 OTHER V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 gRECO CIUAUAL 71ONORY ❑ 3 MONIITORING VAOZE E] 4 GAUAUTD NG C TANK ❑5 MON TORINGTUGROUND R ❑ 8 TESTINGANNUAL ❑ 7 MONITOR INTERSTITIAL ❑ 8 SIR ❑ S WE K LY MANUAL ❑10 MO T HLY TANK❑ NG 95 UNKNOWN ❑99 OTHER VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE M-PLACE) 1.ESTIMATEDDATA U D M AV/VR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH e'2 L SUBSTANCE REMAINING GALLONS I INERT MATERIAL? YES ❑ NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PfRot(Rly,ANWO TH EST OF MY KNOWLEDGE, IS TRUE AND CORRECT TANK OWNERS NAME 6 SIGNAT �R�\ SJ DATE (PI �I RINTED URE) LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY#.5 61 TANK N STATE I.D.# m FA--3 Ft IDILt IFl-O Z O -z PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPUCA^ON-FORM A,UNLESS A CURRENT FORMA HAS BEEN FILED. FOP"C MUST BE COMPLETED FOR INSTALLATIONS. THIS FORM SHOULD BE ACCOMPANIED BY A PLOT PI --ILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE 'FIGROUND STORAGE TANK REGULATIONS FORMS (8-95) �_i I.."