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STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD d d� UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ONE ITEM F-] 2 INTERIM PERMIT F--] 4 AMENDED PERMIT A6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMO f O DBA OR FACILITY NAME WHERE TANK IS INSTALLED: 1313 I. TANK DESCRIPTION COMPLETE ALL ITEMS– SPECIFY IF UNKNOWN A OWNER'S TANK 1.D.R 4:P B. MANUFACTURED BY: R C. DATE INSTALLED(MOIDAYNEAR) Lan jolD. TANK CAPACITY IN GALLONS: /p� II.TANK CONTENTS IFA-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 ❑ 80 EMPTY 1 PRODUCT 1b PREMIUM UNLEADED ❑ 4 GASAHOL ❑ 7 METHANOL ❑ Ic MIDGRADE UNLEADED ❑ 5 JET FUEL ❑ B M85 ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED ❑ 99 OTHER(DESCRIBE M TEEM D.BELOW) D. IF(A.1)IS NOT MARKED, E NAME OF SUBSTANCE STORED C.A 941: 111. 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 W ❑ 3 SINGLE WALL WITH EXTERIOR UNER ❑ 5 I L BLADDER SYSTEM E] 95 UNKNOWN SYSTEM ❑ 2 SINGLE WALL ❑ 4 SINGLE WALL IN A VAULT ❑ 99 ER 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 (PHR19ry T-10 ❑ 9 BRONZE 10 GALVANIZED STEEL ❑ 95 UNKNOWN Al 99 OTHER C.INTERIOR ❑ 1 RUBBER LINED 2 ALKYD LINING ❑ 3 EPDXY ING ❑ 4 PHENOLIC LINING LINING OR ❑ 5 GLASS LINING C—] UNLINED ❑ B5 UN OWN E:] 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH METHANOL? YES O— D.EXTERIOR ❑ 1 POLYETHYLENE WRAP ❑ 2 CO NG VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC CORROSION PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NON 195 UNKNOWN ❑ 99 OTHER E.SPILL AND OVERFILL,BIC. SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) DROP TUBE YES_ NO_ RIKE LATE YES NO_ DISPENSER CONTAINMENT YES_ NO IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR UYLINDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION A U 2 PRESS E A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL A U 2 DOARUE WALLA U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND A U 1 BARE STEEL A U 2 TAINLESS STEEL\J U 3 POLYVINYL CHLORIDE(PVC)A U 4 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U CONCRETE 4,U 7 STEEL W/COATING A U 8 100% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A ly 10 CATHODIC PROTECTIOk, A U 95 UNKNOWN A U 99 OTHER 1 MECXN4CAL IME UM 2 16XTNE53 3 CGMIXNWS IXTE 4 ELECRKMIC UNE 5 AVTOWIIC NW D. LEAK DETECTION ❑ ❑ mxG ❑ NOWT U ❑ gm oE,E ❑ sXGroown ❑ 99 01MER V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 p ONCILI4 TEONORY ❑ 3 MONIITORING VAOZE4 GAUGINAUTOMAG C TANK ❑5 GROUND ❑ 6 ANNUAL TESTINGTANK ❑ 7 CONTINUOUS MONITORING INTERSTITIAL ❑ 8 R ❑ 9 WEEKLYTANK MANUAL 10 TESTMiNGY TANK [:] g5 UNKNOWN E::] 99 OTHER VI.TANK CLOSURE INFORMATIO (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 7 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 8 SIGNATURE) LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY#00 -7& TANK# QQ STATE I.D.# m 3 / d LfLtiz-)if 17116161 PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORMA HAS BEEN FILED. FORM C MUST BE COMPLETED FOR INSTALLATIONS. THIS FORM SHOULD BE ACCOMPANIED BY A PLOT PLAN FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UN�VRGROUND STORAGE TANK REGULATIONS