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�ewcaa STATE OF CALIFORNIA ti STATE WATER RESOURCES CONTROL BOARD ,, a UNDERGROUND STORAGE TANK PER[ /APPLICATION - FORM B COMPLETE A SEPARATE FORM FOR/ACH TANK SYSTEM. / 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION E] 7 PERMANENTLY CLOSER MARK ONLY 1 NEW PERMIT O i ONE ITEM 2 1NTERIM P£RMIT a AMENDED PERMIT 6 TEMPORARY TANK CLOSURE 6 TANK REMOV '•I -� � , r- II l l'f � V'�,�� DBA OR FACILITY NAME WHERE TANK IS INSTALLED: I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN I A. OWNERS TANK I,D.I 1 B. MANUFACTURED BY: r ^�/ C. DATE INSTALLED(MOlDAYIYEAR) I ! D. TANK CAPACITY IN GALLONS. � lo 11.TANK CONTENTS IF A-I IS MARKED.COMPLETE ITEM C to REGULAR UNLEADED � 3 OIES£L ��„ B AVEATIONGAS >` 1 MOTOR VEHICLE FUEL © d OIL B C. t4 PRENNJAI 4;rrlEADFD a GASAHOL © 7 METHANOL u 2 PETROLEUM a' 80 EMPTY 4EJ1 PRODUCT sc !AIDGRALIE Uta.EAS1ED 5 dE7 FUEE. � A M85 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN I 2 WASTE ' 2 FADED El 99 OTHV(DESCRIBE IN ITEU D.BLOW) D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C-AS.N: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A,B.AND C.AND ALL THAT APPLIES IN BOX 0 AND E I DOUBLE WALL CI 3 SINGLE WALL WITH EXTERIOR JNER El 5 INTERNAL BLADDER SYST-EM E] 95 UNKNOWN A. TYPE OFF-7Ei 99 OTHER SYSTEM I 2 SINGLE WALLa SINGLE HALL IN A VAULT 1 BARE STEEL 2 STAINL ESS STEEL j 3 FIBERGLASS C A STEEL CLAD WI RBE?GLASS RENFORCED PLASTIC B. TANK ,MATERIAL 1_f 5 CONCRETE F7 6 POLYVINYL CHLORIDE 7-17 ALUMINUM 6 1OTH METHANOL COMPATIBLE WIFRP (Primary Tank) BRONZE El 10 GALVANIZED STEEL 95 UNKNOWN 99 OTHER El 1 RUBBER LINED Q 2 ALKYD LINING E] 3 EPDXY LINING � a PHENOLIC LINING C.INTERIOR ❑ LINING 08 I5 GLASS LINING � d UNLINED El 95 UNKNOWN 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH IOC% METHANCL? YES— NO_.-. O.EXTERIOR C 3 FIBERGLASS REINFORCED PLASTIC 1 POLYETHYLENE. WRAP � 2 COATING � 3 VINYL WRAP CORROSION 91 NONE CI 95 UNKNOWN r 99 OTHER PROTECTION 5 cATHO0E0 PROTECTION SPiL1.CONTAINMEo�I��NSTALLEr7(YEAR) OVEPFLL�REVEI3TSON EQUIPMENT IN T AI I ED(YEAR) E SPILL AND OVERFILL,BSC. DROP TUBE YES��_ NO S BIKER PLATE YES NO OISPENSEA CONTAINMENT YES N NO IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U iFUNOERGROUND.BOTH IFAPPLICABLE A. SYSTEM TYPE A u 1 SUCTION A IU 2 PRESSURE A U 3 GRAVITY A U a 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 CHLORICE(PVC)A U s RBERGLASS PIPE CORROSION A U S ALUMINUM A U 6 CONCRETE A U 7 STEEL WI COATING A U a l00% METHANOL COMPATIBLE WJFRP PROTECTION A U 9 GALVANIZED STEL A U 10 CATHODICPROTECTION A U 95 UNKNOWN A 99 OTHER id ?^-r IC, 1 ::a"^" uNE,EkK 2�"r.HT ESS 3 UGIT» ��A CCU 99 OZHEIi�� 0. LEAK DETECTION OEIECTOR V.TANK LEAK DETECTION fj�j') q AUTOMATIC TANK 5 GROUND WATER 6 TESN'IUINGTANK n t VISUAL CHECK ❑ 2 MANUAL RECONCILIATION INVENTORY 3 VADOZEmCNI 0 ING v`" GAUGING � MONITORING 7 MON 70AIONUS G INTERSTITIAL g 51R 9 TANK LGA G NGS E to MONTIESTTHLY TANK El 95 UNKNOWN 99 OTHER NG VI.TANK CLOSURE INFORMATION IPERMANENT CLOSURE IN-PLACE) 7.ESTIMATED DATE LAST USED(MOIDAY/YR) i 2 ESTIMATED OUANTRY OF 3.WAS TANK FILLED V YES�= NO G'SUBSTANCE REMAINING GALLONS INERT MATERIAL 7 TF71S FORM HAS BEEN COMPLETED UNDER PENAL i Y OF PERJURY,AND TO 7 HE SEES7 OF MY KNOWLEDGE,IS TRUE AND CORRECT TANK OWNNAME YJ'I4 LJka�=E.�1� .� ' / ,�{�r DATE .' ER'Sr� (PAINTED A=NATURE'} Ox 7 rGl� ' LOCAL AGENCY USE ONLY THE STATE I. .N SER) MPOSED OF THE FOUR NUMBERS BELOW COUNTY N JURISO[CT)ON M FACILITY$ TANK#f STATE 0. 3 7--l I Fc 7 i o PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE .l A,UNLESS A CURENT FORM A HAS 13EM FILED. Ab MUST BE COMPLETED poR INSTALLA� HIS FORM MUST OULD BE AC CMpANIED BY A PLOT��1LEFORM THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THEW GROUND STORAGE TANK REGULATIONS S. THIS FORM OAM B i6 45)