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• STATE OF CAUFORNIA + STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ❑ i NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ON SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ B TANK REMOVED"' DBA OR FACILITY NAME WHERE TANK IS INSTALLED: / 3 / 3 I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A OWNERS TANK I.D.♦ q, B. MANUFACTURED BY: C. DATE INSTALLED(MO/DAY/YEAR) D. TANK CAPACITY IN GALLONS: -550 II.TANK CONTENTS IF A-1 IS MARKED,COMPLETE TEM C. A 1 MOTOR VEHICLE FUEL 4 OIL B. C. 1a REGULAR UNLEADED O 3 DIESEL E] 6 AVIATION GAS 2 PETROLEUM B0 EMPTY ❑ I PRODUCT ❑ Ib PREMIUM UNLEADED ❑ 4 GASAHOL ❑ 7 METHANOL ❑ le MIDGRADE UNLEADED 5 JET FUEL ❑ 8 M85 ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN 2 WASTE ❑ 2 LEADED 99 OTHER(DESCRIBE IN TEND.BELOW) D. IF(A.1)IS NOT MARKED, ENTER NAME OFSUBSTANCE STORED Lo - / C.A S. �OQ 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 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 IN I 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 (Plinuq 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 '15y 6 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER COATING IS LINING MATERIAL COMPATIBLEWITH1001A METHANOL? YES_ NOX D.EXTERIOR ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASNC CORROSION PROTECTION ❑ 5 CATHODIC PROTECTION91 NONE E]95 UNKNOWN ❑ 99 OTHER E.SPILL AND OVERFILL,BIC. SPILL CONTAINME STAL D EAR) OVERFILL PREVENIPMENT 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 3 GRAVITY A U 4 FLEXIBLEPIPING A U 99 OTHER B. CONSTRUCTION A6)1 SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND U I 1 BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A U 4 FIBERGLASS PIPE CORROSION A 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 D. LEAK DETECTION ❑ wnnM/w❑ MEpUNG1 u I UUA 2 UNE MKINU G 3 S I I ST 4 EMMMIC LINE 5 AWOMAnC N 99 OTHER DEn m)A ❑ lE$iNG MOMTCANG LGN DEIE=IR 9NIDOWN V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 RE p CILIATIONAL ORY ❑ 3 M�TORING ZE ❑ 4 GAUGING AUTOMATIC TANK ❑5 MONITORING GROUND �R r-18 TESTINGANNUAL ❑ 7 CONTINUOUS INTERSTITIAL ❑ 8 SIR ❑ 8 WE KGAUGINEKLYUAL ❑ 10 MOSNTHLLY TING TANK 95 UNKNOWN E]99 OTHER MONITORINGVI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) 1.ESTIMATED DATE LAST USED(MO/DAYNR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES NO SUBSTANCE REMAINING GALLONS INERT MATERIAL? [:] ❑ 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 (PRINTED a SIGNATURE) LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW &Z COUNTY# JURISDICTION# FACILITY# TANK M O STATE I.D.# ay -2,1 3 / D1 q I St D 161111,3y . PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORMA,UNLESS A CURRENT FORM A HAS BEEN FILED. FORM C MUST BE COMPLETED FOR INSTALLATIONS.THIS FOR SHOULD BE ACCOMPANIED BY A/P.L�LO,T PV" FILE THISFORM W-/IITTH•THE LOCAL AGENCY IM`PPEMLEMEENTING THE UNDERGROUN D STORAGE TANK TANK R'ElG�U1 LATIONS FORMS (885) La7dc-' I / // l�- I