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�Ct�C STATE OF CALIFORNIA r STATE WATER RESOURCES CONTROL BOARD �, m UNDERGROUND STORAGE TANK PERMIT APPLICATION -FORM B , o} COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. ❑ ❑❑ 1 NEW PERMIT 3 RENEWAL PERMIT L] 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED ON SITE MARK ONLY ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ® 8 TANK R DBA OR FACILITY NAME WHERE TANK IS INSTALLED: ( 14 ti I- L TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN B. MANUFACTURED BY: LJ� 0. OWNER'S TANK I.D.p i� / _ D. TANK CAPACITY IN GALLONS: 000 C. DATE INSTALLED(MOIDAYdYEAR) (0 II.TANK CONTENTS IF A-1 IS MARKED,COMPLETE ITEM C. ❑ 1a REGULAR UNLEADED ❑ 3 DIESEL ❑ 6 AVIATIONGAS 0. y-I 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C� ❑ 1b PREMIUM UNLEADED ❑ 4 GASAHCL ❑ 7 METHANOL ❑ 2 PETROLEUM El 80 EMPTY 5 PRODUCT li�4 Te MIDGRADE UNLEADED ❑ 5 JET FUEL ❑ 8 MB-9 ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED ❑ 99 OTHER(DESCRIBE IN ITEM D.BELOW) D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED O.A.S. 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 ❑ 99 OTHER ❑ SYSTEM 2 SINGLE WALL 4 SINGLE WALL IN A VAULT 1 BARE STEEL ❑ 2 STAINLESS STEEL 3 FIBERGLASS ❑ 4 STEEL CLAD WFIBERGLASS REINFORCED PLASTIC 8. TANK MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ B 100% METHANOL COMPATIBLE WIFRP ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER (Primarylank) F-1 9 BRONZE ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING C.INTERIOR ❑ 6 UNLINED 95 UNKNOWN El 99 OTHER LINING OR F--] 5 GLASS LINING COATING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES..— NO— D.EXTERIOR ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC CORROSIONr 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER �ES�POILL ECTION ❑ 5 CATHODIC PROTECTION SPILLCONTAWMENT INSTALLED(YEAR} OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) AND OVERFILL,BtC. DROP TUBE YES NO STRIKER PLATE YES NO DISPENSER CONTAINMENT YE5 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 �Al�81NGLE WALL A U 2 DOUBLE WALL A U 3 L.fNED TRENCH A U 95 UNKNOWN A U 99 OTHER {'. MATERIAL ANDTEEL A U 2 STAINLESS STEEL A I! 3 POLWINYL CHLORIDE(PVC)A U 4 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL Wf COATING A U 8 1Q0% METHANOL COMPATIBLE WfFRP 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER PROTECTION A U 9 GALVANIZED STEEL A U 1 MECHANICAL UNE LEAK W2 UNE TIGHTNESS ❑3 CONTINUOUS INTERSTIT1At �i 4 ELECTRONIC UNE ❑5 AUTOMAT7C PUMP (-1 49 OTHER D. LEAK DETECTION R QE7ECTOR ll1SJ TEsnNC MCNITOAING I—J BEAK rcm,,TOR sr+uTmw.+ LJ V.TANK LEAK DETECTION ❑ 2 MANUAL INVENTORY 3 ADOZ RING 4 GAUL MGIC TANK ❑ 5 MON TORINGGROUND WATER ❑ 8 TESTINGTANK 1 VISUAL CHECK 7 MONITORING_ INTERSTITIAL 0 8 SIR ❑ 9 WEEKLY GAUGING �10 MONTHLY TANK ❑ 95 UNKNOWN ❑99 OTHER VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) 2.ESTIMATED QUANTITY OF [flN:ER �MATE �TH YES ❑ NO1.ESTIMATED DATE LAST USED{MOIDAY/YR) St1BSTANGE REMAINING THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THF BEST OF MY KNOWLEDGE,DATE TRUE AND CORRECT TANK OWNERS NAME G� C?Tltlsn() r y �� (PRINTED B SIGNATLFRE} (0( �^:.�yI ou LOCAL AGENCY USE ONLY THrT E STATE I.D. e R IS CCfMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY# TANK# STATE I.D.# o `' ,? PERMIT NUMBER PERMIT APPROVED BYIDATE PERMIT EXPIRATION DATE I— -FORM A,UNLESS A CURRENT FORM A HAS 13EEN FILE . F01M MUST BE COMPLETED THIS FORM MU SHOULD O ACCOMPANIED BY AIPLOT PILE THIS FORM W TH THE LOCAL AGENCY IMPLEMENTING THE GROUND SMRAGE TA KRREGULATII.. FORM B {s•ss)