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y � 6=.a STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD o UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. �1 MARK ONLY 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7..-PERMANENTLY CLOSED ON SITE ONE ITEM 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ dZ K qE OV 'i I DBA OR FACILITY NAME WHERE TANK IS INSTALLED: !(�' 1 �'' �� ` ✓ �) _ I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A OWNER'S TANK I.D.p B. MANUFACTURED BY: / A CM+jjq_ C. DATE INSTALLED(MO/DAYNEAR) 7 '� IJ �, D. TANK CAPACITY IN GALLONS: � \I II.TANK CONTENTS IF A-1 IS MARKED,COMPLETE ITEM C. A 1 MOTOR VEHICLE FUEL ❑ 4 OIL B, C Ya.REGULAR UNLEADED ❑ 3 DIESEL ❑ 6 AVIATIONGAS ❑ 2 PETROLEUM ❑ 80 EMPTY 1 PRODUCT Z PREMIUM UNLEADED ❑ 4 GASAHOL ❑ 7 METHANOL ❑ UNLEADED ❑ 5 JET FUEL 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE lc MIDGRADE ❑ 8 M85 ❑ 2 LEADED ❑ 99 OTHER(DESCRIBE IN ITEM D.BELOW) D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S.p 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 W-'J 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 5 INTERNAL BLADDER SYSTEM ❑ 95 UNKNOWN SYSTEM ❑ 2 SINGLE WALL ❑ 4 SINGLE WALL IN A VAULT ❑A ,1 99 OTHER B. TANK ❑ 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS I=f 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM T❑-" 8 100% METHANOL COMPATIBLE W/FRP (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER C.INTERIOR ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING LINING OR ❑ 5 GLASS LINING ❑ 6 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 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 ❑95 UNKNOWN ❑ 99 OTHER E.SPILL AND OVERFILL,6(C. SPILLCONTAINMEN NSTALLED(YEAR) OVERFI REVENTION EQUIPMENT INSTALLED(YEAR) DROP TUBE VES F+ NO STRIKER PLATE YES NO_ DISPENSER CONTAINMENT VES NO IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND,BOTH IF APPLICABLE IQ A. SYSTEM TYPE A U 1 SUCTION 2 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL AW 2 DOUBLE WALL A U 3 LINED TRENCH A U 85 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 4 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL W/COATING A U 8 100% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION 1 MEQWIICAL UNE LFAK , 2 UNE IIGH1NE55 3 CONi1NUW6 INTEBSTRML d ELECTRONIC NNE 5 AUTGANTIG PUMP,❑ OETECfOR TESTING ❑ MOMTORMG ❑ LEAK DETECTOR ❑ SHU100WN 99 OTHER V.TANK LEAK DETECTIONI'llJ/,F'd1ZQl��(G CS�TIVk �II�Tr�owN �,y❑T_,� i VISUAL CHECK ❑ 2 MANUAL RECONCILIATIONORV E] 3 VADE MONITORING ❑ 4 AUTOMATIGAUGING C TANK ❑5 MON TORINGGROUND WATER ❑ 6 TESSTTIINGTANK 7 MONITORINGCONTINUOUS INTERSTITIAL ❑ B SIR ❑ 9 TANKGAUGINGAL ❑ 10 MESNG TIY TANK ❑ 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) 1.ESTIMATED DATE LAST USED(MO/DAY/YR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES E::] NO ❑ SUBSTANCE REMAINING GALLONS INERT MATERIAL 7 THIS FORM HAS BEEN C LETE fi UNQER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT TANK OWNER'S NAME(PRINT EDd SIGNATURE) A �-- -i p 1 0 �� / 14s,d DATE / LOCAL AGENCY USE ONLU Y THE S ATE I.D.NI IS COMPOSED OF THE FOUR NUMBERS BELOW 1 COUNTY# JURISDICTION# FACILITY# J-A-' TANK# ' STATE I.D.# m PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION UATE THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLIqC�"{pN-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. FO��ppLLC MUST BE COMPLETED FOR INSTALLATIONS. THIS FORM SHOULD BE ACCOMPANIED BY A PLOT PWLE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THEIWGROUND STORAGE TANK REGULATIONS FORM B (6-95)