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• STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD ;�. jig UNDERGROUND STORAGE TANK PERMIT APPLICATION -FORM B I � �11,.O1.Y,Y.O COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ON SITE ONE REM ❑ 2 INTERIM PERMIT F4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: g EA rO A/ it(v 98 I. TANK DESCRIPTION COMPLETE ALL ITEMS– SPECIFY IF UNKNOWN A OWNER'S TANK I.D.• 3 B. MANUFACTURED BY: M 0 DERN WELD IA/G C. DATE INSTALLED(MCIDAWYEAR) I 8 D. TANK CAPACITY IN GALLONS: 10" II.TANK CONTENTS IFA-1 IS MARKED.COMPLETE ITEM C. A C1 MOTOR VEHICLE FUEL ❑ 4 OIL a C, la REGULARUNLEADED O 3 DIESEL ❑ 6 AVIATION GAS 10 PREMIUM UNLEADED ❑ 4 GASAHOL ❑ ] METHANOL ❑ 2 PETROLEUM ❑ 80 EMPTY CEI7 PRODUCT ❑ Ic MIDGRADE UIIEADED 5 JET FUEL ❑ 8 M85 ❑ 3 CHEMICALPRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED 89 OTHER(DESCRIBE N TEMO.BELOW) D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S.f: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.8,AND C.AND ALL THAT APPLIES IN BOX D AND E L A. TYPE OF J i DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 5 INTERNAL BLADDER SYSTEM ❑ 95 UNKNOWN SYSTEM I❑–I�2 SINGLE WALL E-14 SINGLE WALL IN A VAULT ❑ 99 OTHER LJ B. TANK I 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 (NMOYT$nK) ❑ 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 EEJ�s 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 ED-4 FIBERGLASS REINFORCED PLASTIC CORROSION PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER E.SPILL AND OVERFILL,6LC. SPILL CONTAINMENT IN LED(YEAR) El OVERFILL 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 A U 1 SUCTION A 2 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER S. CONSTRUCTION A U 1 SINGLE WALL AW 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) U 4 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEELNCOATING A U 8 100% METHANOL COMPATIBLE NFRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION t MECNunaL ME LEAN 2 UNE TNHINE!M 3 WIRINUWS NTER699N ELECTRONIC UNE 5 AVTOIwTw mw ❑ QEIECTOR ❑ TESRNO MONTOIIING [fAK DE1ECi0R ❑ SNUTOOWN ❑ 99 OTHER V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 RECONCILIATIONNUAL ORY ❑ 3 MONIITORING OZE �4 GAUGING AUTOMATIC TANK ❑5 GROUND MONITORING TER ❑ 6 ANNUALTESTING �7 CONTINUMON TOR U INTERSTITIAL ❑ 8 SIR E] 9 WEEKLY MANUAL ❑10 MES NGY TANK ❑ 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PUCE) 1.ESTIMATED DATE LAST USED(MO/DAV/YR)__72.ESTIMATED QUANTITY OF 3.WAS TANK FILLED NTH SUBSTANCE REMAINING GALLONS INERT MATERIAL 7 YES [:] NO❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT TANK OWNER'S NAME DO U G /Y,\A 5 S A;RoFO G DATE q (PRINTEG A SIGNATURE) 1 DI_ VI—Tp'A'. AI, (46-91 LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY W JURISDICTION x FACILITY k TANK M STATE I.D.# m PERMIT NUMBER PERMIT APPROVED BYIDATE PERMIT EXPIRATION DATE THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORMA HAS BEEN FILED. FORM C MUST BE COMPLETED FOR INSTALLATIONS. THIS FORM SHOULD BE ACCOMPANIED BY A PLOT PLAN. FILE THj*M WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROU" ORAGE TANK REGULATIONS FORM B (695)