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STATE OFCALIFORNIA �sG+ STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION -FORM B •"� COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT •`.o - ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOS D TE ❑ 8 TEMPORARY TANK CLOSURE 5 TANK REMOVED I DBAOR FACILITY NAME WHERE TANK IS INSTALLED: I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN �II� A OWNER'S TANK I.D.• 3 9-S65-Oq cy - OZ B. MANUFACTURED BY; Unknowr� � C. DATE INSTALLED(MOIDAYNEAR) 1021 c? D. TANK CAPACITY IN GALLONS: 55-D II.TANK CONTENTS IFA-1 IS MARKED,COMPLETE ITEM C. A. ❑ 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C. to REGULAR UNLEADEDV4GASAHOL EL O 6 AVIATION GAS ❑ 2 PETROLEUM BO EMPTY 1 PRODUCT ❑ 1G PREMIUM UNLEADED ❑ 7 METHANOL3 CHEMICAL PRODUCT ❑ 9S UNIOJOWN 2 WASTE 1c MIDGRADE UNLEADED FUEL ❑ B MBS2 LEADED Ei1(DESCRIBE IN REM D.BflOtAiD. IF(A1)IS NOT MARKED. ENTER NAME OF SUBSTANCE STORED 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 O 3 SINGLE WALL WITH EXTERIOR LINER ❑ 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 ❑ 8 100% METHANOL COMPATIBLE W/FRP (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER C.INTERIOR ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING LINING OR ❑ 5 GLASS UNING ❑ 6 UNLINED C9 95 UNKNNO ❑ 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 1001,6 METHANOLS 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,ltC. 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 A U 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 U 2DOUBLE 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 W/COATING A U 8 100% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER I, D. LEAK DETECTION 01 IEWIa�AL IME" 1]2 UNE Tm1111F% 0 3 CGm =$INI6RSTnY ❑A ELECD10mC UNE ❑5 AUTOIMTIC RUED 99 OTHER tJTI I'+AIDW V\ O Vrm —I TESTING MONfORMG Mx OE1ECRIR SHII}WWN V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 gMECO CIUATIONAL ORY ❑ 3 MONIITORING OZE ❑ 4 GAUGING AUTOMATIC TANK ❑5 GROUND MONTORINGTER ❑6 TTEESTINGTANK ❑ 7 CONTINUOUS INTERSTITIAL ❑ 8 SIR ❑ING 9 WEEKLY MANUAL ❑10 MONTHLY TANK 95 UNKNOWN ❑99 OTHER TNG VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PUCE) 1.ESTIMATED DATE LAST USED(MO/DAYNR) 2. SUBSTANCE TED UANTIT OF GALLONS 3 WAS 7H YES [:] NO I"Wo THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT TANK OWNER'S NAME DATE (PRIMED!SIGNANRE) El> S LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY! JURISDICTION a FACILITY A 7268 TANK M STATE I.D.# m = Ldole-liTTEd p p PERMIT NUMBER PERMIT APPROVED BYIDATE PERMIT EXPIRATION DATE 0 (I 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 INSTALLA NS.THIS FORM SHOULD BE ACCOMPANIED BY A PLOT PLAN ^LE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDFgGROUND STORAGE TANK REGULATIONS FORM 8 (6.95) \� FOROGM6R7