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STATE OF CALIFORNIA %..00 STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B =° COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT 7 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ONSITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 8 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED r-- oll DBA OR FACILITY NAME WHERE TANK IS INSTALLED: O /Ll/ 42gA/� I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A OWNER'S TANK I.D.4 B. MANUFACTURED BY: O i 4V C. DATE INSTALLED(MOIDAY/YEAR) 7, D. TANK CAPACITY IN GALLONS: D p ILTANK CONTENTS IFA-11S MARKED,COMPLETE ITEM C. A gR 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C. 1e REGULAR UNLEADED ❑ 3 DIESEL ❑ 8 AVIATION GAS ❑ 2 PETROLEUM ❑ 80 EMPTY 1 PRODUCT 1b PREMIUM UNLEADED ❑ 4 GASAHOL ❑ 7 METHANOL ❑ 1e MEGMDE UNLEADED ❑ 5 JET FUEL ❑ 8 M05 3 CHEMICALPRODUCT ❑ 95 UNKNOWN 2 WASTE ❑ 2 LEADED ❑ 99 OTHER(DESCRIBENIIEMD.BELOW) D. IF(A1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A S. 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 I DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 5 INTERNAL BLADDER SYSTEM ❑ 95 UNKNOWN SYSTEM pf 2 SINGLE WALL ❑ 4 SINGLE WALL IN A VAULT ❑ 99 OTHER B. TANK ❑ I BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS C14 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL F-15 CONCRETE ❑ 8 POLYVINYL CHLORIDE E] 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP (PHmvy Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER C.INTERIOR ❑ I RUBBER UNED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING LINING OR ❑ 5 GLASS LINING 5(e UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER COATING IS UNING MATERIAL COMPATIBLE WITH 10D% METHANOL? YES— NO— D.EXTERIOR 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC CORROSION PROTECTION ❑ S CATHODIC PROTECTION ❑ 81 NONE ❑95 UNKNOWN BB OTHER IE SPILL AND OVERFILL,BU:. 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 ABOVE GROUND OR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION A U I SINGLE WALL Aa�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 8 CONCRETE A U 7 STEEL W/COATING A U 8 100% METH NOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN Aa?99 OTHER V-/4eD�. D. LEAK DETECTION t La?auacAL uxE 1EAA ❑z w[rKunxEss ❑3 wrII9AIaua wlEmm�AL ❑4 BECIRGIIC wE ❑5 Alnownc Pule 99 OTHER DRECfgi IESTHG IIMTO IrAa OLTECiGR SMIIWWN V.TANK LEAK DETECTION I❑ 1 VISUAL CHECK ❑ 2 MANUAL INVENTORY [:] 3 VLIATION ADOZE NG rK 4 AUTOGAUGMAT C TANK ❑5 GROMONUND NWA ER ❑ 8 ANNUALTESTINTANK Y� 7 CONTINUOUS W MONITORINGINTERSTITIAL ❑ 8 SIR ❑ 9 TANEK GA=LL ❑10 TESTIMONTNGY TANK ❑ 95 UNKNOWN ❑99 OTHER VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PUCE) 1.ESTIMATED DATE LAST USED(MC/DAY/YR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED NTH YES ❑ NO❑ SUBSTANCE REMAINING GALLONS INERT MATERIAL 7 THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE IS TRUE AND CORRECT TANK OWNER'S NAME DATE (PRINTED 8 SIGNATURE) LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION k FACILITY p TANK# STATE I.Dl � y O 16 PERMIT NUMBER PERMIT APPROVED BYIDATE PERMIT EXPIRATION DATE THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. FORM- MUST BE COMPLETED FOR INSTALLATIONS. THIS FORM SHOULD BE ACCOMPANIED BY A PLOT PU 'ILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE V RGROUND STORAGE TANK REGULATIONS FOR"&R7 FORM B (695) I