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*tsv�ncrs STATE OF CALIFORNIA p 01 STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B I COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. E-3 ❑ 7 PERMANENTLY CLOS�'Dlo - E MARK ONLY 1 NEW PERMIT 3 RENEWAL PERMIT ❑ 5 CHANGE R INFORMATION ONE ITEM ❑ 2 INTERIM PERMIT ❑ a AMENDED PERMIT 176 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: r �'I2.Y� �� } I I. TANK DESCRIPTION COMPLETE ALL ITEMS SPECIFY IF UNKNOWN B. MANUFACTURED BY: �. + �;I��,/1e A OWNER'S TANK L D.q L� i7 —(�� D. TANK CAPACITY IN GALLONS: C. DATE INSTALLED(MOIDAYNEAR) I+//, II.TANK CONTENTS IF A-1 IS MARKED,COMPLETE ITEM C. ❑ ❑ 6 AVIATION GAS C ❑ 1a REGULAR UNLEADED 3 DIESEL 1 MOTOR VEHICLE FUEL ❑ 4 OIL B 1b PREMIUM UNLEADED ❑ 4 GASAHOL ❑ 7 METHANOL ❑ 2 PETROLEUM ❑ 60 EMPTY 1 PRODUCT ❑ 1c MIDGRACE UNLEADED ❑ 5 SET FUEL ❑ B M85 ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED ❑ 99 OTHER{DESCRIBE IN ITEM D.BELOW) IS SN MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S-N: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A,B,AND C.AND ALL THAT APPLIES IN BOX D AND E 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 5 INTERNAL BLADDER SYSTEM ❑ 95 UNKNOWN A. TYPE OF ❑ 4 SINGLE WALL IN A VAULT ❑ 99 OTHER SYSTEM 2 SINGLE WALL 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGI-ASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B. TANK MATERIAL ❑ 5 CONCRETE ❑ fi POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL GDMPATIBLE W1FRP (primary Tank Fsl g BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER '�❑1 } RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING G.INTERIOR 6 UNLINED L-1 95 UNKNOWN ❑ 99 OTHER LINING OR ❑ 5 GLASS LINING COATING IS LINING MATERIAL COMPATIBLE WITH JOG% METHANOL? YES_ NO— D.EXTERIOR } POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC CORROSION91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER PROTECTION ❑ 5 CATHODIC PROTECTION ❑ SPILLCONTAINIv1ENT.INSTALLED(YEAR) OVERFILL(?REVELATION EQUIPMENT INSTALLED(YEAR) E.SPILL AND OVERFILL,etC. DROP TUBE YES��1lhh NO STRIKER PLATE YES r 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 2 PRESSURE A U 3 GRAVITY A U 4 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 CHLORIDE(PVC)A U 4 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEELWICOATING A U e 100% METHANOL �6M'PAT //SRP I� PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A 'l�99 OTHER� 1 �J� 1 MECHANICAL LINE LEAK 2 LINE TIGHTNESS 3 CONTINUOUS INTERSTITIAL ❑d LEAKELECDETECRONICTOR UNE ❑5 SHUTDOWNAUTOMATIC PUMP ❑ 99 Qr11ER D. LEAK DETECTION TEsnNs MONiToalNc LEAK nETEcroR s IuroowN DETECTOR V.TANK LEAK DETECTION 2 MANUAL INVENTORY ❑ 3 VADOZE 4 AU GNGIC TANK :FE7 5GROUN W TER ❑ 6 TNNUAI-TANKVISUAL CHECK ❑ RECONCILIAT4ON MONITORING7MONTORO�INTERSTITIAL ❑ g SIR g WEEKLY TANK GAGINGAL ❑r0 MOS INGY TANK g5 UNKNOWN ❑g9 OTHER VL TANK CLOSURE INFORMATION(PERMANENT CLOSURE $N-PLACE) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES ❑ NO Q 1.ESTIMATED DATE LAST USED(MOfDAYlYR} SUBSTANCE REMAINING GALLONS !NEAT MATERIAL? THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNO WLEDDGAE,,EIS TRUE AND CORRECT (PRINTED S SIGNATURE) J 4 / / O LOCAL AGENCY USE ONLY THE STATE 1. .N BER 13. MPOSED OF THE FOUR NUMBERS BELOW TANK# COUNTY# JURISDICTION 7TE FACILITY k STATE 04 �❑ ❑❑ l d 3 © 3 PERMIT APPROVED PERMIT EXPIRATION DATE ( -7 Grg PERMIT NUMBER ! BEEN MUST BE MPLETED FOR THIS FORM MUST HOULD ACCOMPANIED ACCOMPANIED BY AIPLOT PI LLE TMS FORM UNLESS TH THE CLOCALURRENT FORM A AGENCY IM S MENTINGTHE*GROUND STORAGE E TANK REGULATIONS NS.THIS FORM FORM B (6-95)