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STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD a UNDERGROUND STORAGE TANK PERMIT APPLICATION-FORM BCOMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM.MARK ONLY ❑ 1 N�,P ONE ITEM ERMT ❑ 3 RENEWAL PERMIT ❑ 2 INTERIM PERMITO 4 AMENDED PERMIT ❑ 5 CHANGE OF INFORMATION O 6 TEMPORARY TANK CLOSURE 6 TANK REMOVED ❑ 7 PERMANENTLY CLOSED ON SITE DBA OR FACILITY NAME WHERE TANK IS INSTALLED: ® I, TANK DESCRIPTION SIR RN S jf COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A OWNERS TANK 1.D.♦ _70 - - 15 C. DATE INSTALLED(MO10AY/YEAR) L 8. MANUFACTURED BY: �.N TANK CAPACIry IN GALLONS: C 1,.J II,TANK CONTENTS IFA-1 IS MARKED,COMPLETE TD. IV EM C. A ® I MOTOR VEHICLE FUEL { OIL B ❑ 2 PETROLEUM ❑ BO EMPTYC. gEGULAR UNLEADED ❑ 3 DIESEL ❑ 3 CHEMICAL PRODUCT ® 1 PRODUCT ❑ Ile PREMIUM UNLEADED6 AVIATION O A GASAHOL ❑ 7 METHANOL ❑ 95 UNKNOWN ❑ 2 WASTE ® Ic MDGgADE UNLEADED O 5 JET FUEL ❑ e MBS D. IF(A.1)ISNOTMARKED, ENTER NAME OFSUBSTANCE STORED ❑ 2 LEADED ❑ 99 OTHER(DESCRBE N TEM D.BELOW] III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A,B,AND C.AND ALL THAT APPLIES IN BOX D AND E C.A S.N: A. TYPE OF ❑ 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH SYSTEM ��/7 EXTERIOR LINER El INTERNAL BLADDER SY �l 2 SINGLE WALL 11d SINGLE WALL IN A VAULT 6TEM ❑ 95 UNKNOWN ❑ 99 OTHER B. TANK 1 BARE STEEL ❑ 2 STAINLESS STEEL MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ STEEL CLAD OL COMPATIBLE EWIFRP PLASTIC ❑ 10 GALVANIZED STEEL 95 UNKNOWN O B 1OTH METHANOL COMPATIBLE W/FRp ��TaA� 9 BRONZE ❑ ❑ Q 99 OTHER C.INTERIOR ❑ I RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ A PHECUC LINING LINING OR ❑ 5 GLASS LINING 6 UNLINED ❑ 95 UNKNOWN COATING` E:] 99 OTHER IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ No— D. O_D CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION91 NONE ❑95 UNKNOWN 99 OTHER E SPILL AND OVERFILL,etc. SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) DROP TUBE YES_ NO_ STRIKER PLATE VES_ NO DISPENSER CONTAINMENT YES_ NO_ IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND,BOTH IF APPUCABLE A. SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U d FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH p U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND A U I BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A U < FIBERGLASS PIPE CORROSION A 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL W/COATING A U 8 10D% 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 ❑I IEcq M LANE OF ❑2 LANE TK.K % ❑3 cauMas NTRs1mu m K s AurowTK OETECfIX1 TF61NIi YONTORRl9 ❑N LFUtBEcOEIECIIXL ❑ MOP 3XUIWV,H ❑ 99 OTHER V.TANK LEAK DETECTION ❑ I VISUAL CHECK ❑ 2 FIECO CIUATIANUAL ON RY ❑ 3 AI�NITZORING ❑ • GAUGNGIC TANK ❑ 5 MONTORING�R ❑ 6 TESTING TNK ❑ 7 MONITORING INTERSTITIAL ❑ 8 SIR ❑ 9 WEEKLY MANUAL ❑10 MONTHLY TANK O 95 UNKNOWN ❑ 99 OTHER TANK AGING TESTING VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) 1.ESTIMATED DATE LAST USED(MOIDAYNR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES E::] NO SUBSTANCE REMAINING GALLONS INERT MATERIAL? TH/S FORM HAS BEEN qP902YED UNDER PENALTY OF PE JU Y,AND TO THE BE F MY KN LEDGE, IS TRUE XO CORN CT TANK OWNER'S NAM DATE / (PRWTEDd BIGNA (JQ' LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER OMPOSED OF TH OUR NUMBERS BELOW COUNTY M JURISDICTION A FACILITY M TANK N STATE I.D:# m •NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. FORM C MUST BE COMPLETED FOR INSTALLATIONS. THIS FORM ULD BE ACCOMPANIED BY A PLOT PUN. FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS