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STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD c'4 UNDERGROUND STORAGE TANK PERMIT APPLICATION -FORM B COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ ONE REM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT7 PERMANENTLY CLOSED ON SIT ❑ 6 TEMPORARY TANK CLOSURE 8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: 'y'Ot( A1, LICK, I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A OWNERS TANK I B. MANUFACTURED C. DATE INSTALLED(MOIDAWYEAR) D. TANK CAPACITY IN GALLONS: t d n{Pl II.TANK CONTENTS IF A-I IS MARKED,COMPLETE ITEM C. ✓ V p 1 MOTOR VEHICLE FUEL O 4 OIL B. C. la REGULAR UNLEADED 3 DIESEL ❑ 8 AVIATIONGAS ❑ 2 PETROLEUM ❑ BO EMPTY ❑ 1 PRODUCT ❑ Ib PREMIUM UNLEADED 4 GASAHOL ❑ 7 METHANOL ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ IC MIDGRADE UNLEADED I^I�� 5 JETFUEL ❑ 8 MRS ❑ 2 LEADED u 99 OTHER(DESCRIBE W REM D.BELOP) D. IF(A1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S.t III. 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 WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 5 INTERNAL BLADDER SYSTEM ❑ 95 UNKNOWN SYSTEM I�T 2 SINGLE WALL ❑ 4 SINGLE WALL IN A VAULT ❑ 99 OTHER R. TANK )C._l 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD N FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE WIFRP (PrimarYTmIQ ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER C.INTERIOR ❑ I RUBBER LINED ❑jr2 ALKYD LINING ❑ 3 EPDXY LINING F-14 PHENOLIC LINING LINING OR ❑ 5 GLASS LINING I7yf-6 UNLINED F-195 UNKNOWN ❑ 99 OTHER COATING IS LINING MATERIAL COMPATIBLETWRH 100% METHANOL? YES_ NO— D.EXTERIOR ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC CORROSION PROTECTION ❑ 5 CATHODIC PROTECTION� 91 NONE E]95 UNKNOWN E::] 99 OTHER E SPILL AND OVERFILL,BIC. SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) DROP TUBE YES_ NO_ STRIKER PLATE YES_ NO DISPENSER CONTAINMENT YES NO IV.PIPING INFORMATION CIRCLE A IF ABOV n ROUND OR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U I SUCTION U 2 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION 1 SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND �tA 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 8 CONCRETE A U 7 STEELNCOATING A U B 100% METHANOL COMPATIBLEWIFRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION ❑I LECIW4w leaf Ir<Alc 0"'TIS ❑3 mBamuL ❑4 ❑5 MMal�lnc°ulm ❑ 99 oTHER V.TANK LEAK DETECTION I VISUAL CHECK ❑ 2 MANUAL UATONORY ❑ 3 VADOZORING ❑ 4 GAUGING C TANK ❑ 5 GROUNDWATER WATER ❑8 ANNUAL 7 MONITORING INTERSTITIAL 8 SIR ❑ 9 WEEKLY NK MANUAL ❑ 10 TETNGY TANK ❑ 95 UNKNOWN O 99 OTHER VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) 1.ESTIMATED DATE LAST USED(MMAWYR) 2. SUBSTANCE EMAINI OF S V GALLONS 3.WASH PNTK FILLERD WITH .ES ❑ NI THIS FORM HAS BEEN COMPLETED UNDER PENH PE URY,AND TO THE BEST OF MY KNOWLEDGE IS TRUE AND CO ECT TANK-BWI49R`S NAME I/n n/J.''� /'�rA DATE /A / (PRINTID A SIGNATURE) 0.tL . cla I� k,, f✓yl}'J�r&yy s 1' �0_1 G LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY II JURISDICTION t FACILITY M TANK M STATE ILD:# PERMIT NUMBER PEflM1T APPROVED BYIDATE PERMIT EXPIRATION DATE THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLIC"'WN-FORMA,UNLESS A CURRENT FORMA HASBEB7RLED. FOP4 C MUST BE COMPLETED FOR INSTALLATIONS.THISFORLT SHOULD BE ACCOMPANIED BY A PLOT PIIv9LE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE�AGROUNNDD STORAGE TANK REGULATIONS FORM 8 (6-95) �.�T 3--'98 v '6