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• a STATE OF CALIFORNIASTATE WATER RESOURCES CONTROL BOARDUNDERGROUND 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 ❑ 7 PERMANENTLY CLO ED ON ITE ONE REM F__] 2 INTERIM PERMIT �d AMENDED PERMIT ❑ ..6TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED ) DBA OR FACILITY NAME WHERE TANK IS INSTALLED: BG—A c©N -T6/ S / I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN to I9 A OWNER'S TANK 1.D.# 2 B. MANUFACTURED BY/VI O D CA/' V,/EL p/A/C C. DATE INSTALLED(MODAYNEAR) /7F7 D. TANK CAPACITY IN GALLONS: oO� II.TANK CONTENTS IF A-1 IS MARKED,COMPLETE ITEM C. A ©MOTOR VEHICLE FUEL ❑ 4 OIL 0. C. ❑ le REGULVi UNlEAOED ❑ 3 DIESEL ❑ 6 AVIATION GAS UNLEADEDb PREMIUM F-12 PETROLEUM ❑ 80 EMPTY PRODUCT ❑ 1.MIIDDSRADEUEAADED ❑ 5 JE SFUMETHANOL EL ❑ 8 M85 ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ [ WASTE ❑ 2 LEADED ❑ 99 OTHER(DESCRIBE IN ITEM D.BELOM D. IF(A.1)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 LJ ' DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 5 INTERNAL BLADDER SYSTEM ❑ 95 UNKNOWN SYSTEM ❑ 2 SINGLE WALL ❑ 4 SINGLE WALL IN A VAULT ❑ 99 OTHER B. TANK 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP (P"Moy T#Rk) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER C.INTERIOR ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY UNING ❑ 4 PHENOLIC LINING LINING OR ❑ 5 GLASS LINING EEI8uNUNED ❑ 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,BIO. SPILL CONTAINMENT IN-STALLED(YEAR) OVEflFILL PREVEMION EQUIPMENT INSTALLED(NEAR) DROP TUBE YES_ NO_ STRIKER PLATE YES `l NO DISPENSER CONTAINMENTNT YE� NO IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL A02 DOUBLE WALL A U 3 UNED 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 STEEL W/COATING A U B 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 ❑ ❑ OEIECfORA1 W Oo URE ❑LSM' 2 UIC MWKM eoxrrtuous NTERs1mu BECmal4C UN; 5 AUTOMAnC MW TESRNOK MOIITGRNG [GX ODECTON SHUTWWN ❑ 99 OTHER V.TANK LEAK DETECTION y ,�❑ 11 VISUAL CHECK E] 2 RECONCIUATIONNUAL ORY ❑ 3 MAONNIITORING ZE 4 GAUGING MO TANK ❑ 5 MONITORINGTER ❑ 6 TESTINGTANK `--' MONITORING NUOUS INTERSTITIAL ❑ 8 SIR ❑ 9 7p EK LAUGINGAL ❑10 TESTING Y TANK ❑ 15 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) 1.ESTIMATED DATE LAST USED(MO/DAYNR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES ❑ NO SUBSTANCE REMAINING GALLONS INERT MATERIAL? THIS FORM HAS BEEN COMPLETED UNDERPENALTYOF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT TANK(PNINTM A OWNERS IGNATURE) E O J M J 5,4/e O )C�Ie V L 1/e/I M Al,'_ DATE O LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW o 7 CO�# JURISDICTION# FACILITY# O TANK# DDS STATE LD:# 13ggp5 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 FORMS (6-95)SHOULD BE ACCOMPANIED BY A PLOT P FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE AGROUND STORAGE TANK REGULATIONS &/2,1��