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• STATE OF CALIFORNIA • ^`".�.;' STATE WATER RESOURCES CONTROL BOARD o UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B tl`� ( COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT 3 RENEWAL PERMIT P�lr5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ONSITE ONE REM ❑ 2 INTERIM PERMIT 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED S, DBA OR FACILITY NAME WHERE TANK IS INSTALLED: 'Expajun A} 1_ 9 I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A OWNER'S TANK I.D.# a _'L B. MANUFACTURED BY: / C. DATE INSTALLED(MO/DAY/YEAR) ` D. TANK CAPACITY IN GALLONS: ILTANK CONTENTS IFA-11S MARKED,COMPLETE ITEM C. A 2 MOTOR VEHICLE FUEL ❑ BO OIL B 1 PRODUCT O 1e REGULIR UNLEADED ❑ 3 DIESEL ❑ 6 AVIATIONGAS ❑ ❑ +a. I❑alb PREMIUM UNLEADED ❑ 4 GASAHOL ❑ 7 METHANOL ❑ 3 CHEMICALPRODUCT ❑ 95 UNKNOWN �❑ 2 WASTE - 5`1c MIDGRADE UNLEADED ❑ 5 JETFUEL ❑ 8 M85 ❑ 2 LEADED ❑ 99 OTHER(DESCRIBE IN ITEM D.BELOW) D. IF[AA)IS NOT MARKED, ENTER NAME OFSUBSTANCE STORED C.A S.M: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A,B.AND C,AND ALL THAT APPLIES IN BOX D AND E T A. TYPE OF 'L<TR1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 5 INTERNAL BLADDER SYSTEM ❑ 95 UNKNOWN LI SYSTEM "72 SINGLE WALL El 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 (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 1001.4 METHANOL? YES_ NO— D.EXTERIORF71 POLYETHYLENE WRAP E] 2 COATING ❑ 3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC CORROSION PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER E.SPILL AND OVERFILL,11C. SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(NEAR) DROP TUBE VES 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 Ao PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL A U 2 DOUBLE WALL Ao 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER j 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 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 WCN Ie UNE UDX 2 UNE RGNTNESS 3 CMINU eS aRERSRnu 4 EU:=m UNE S AUTONUTC PUMP GEIECIOR TESi1NG MONITORING ❑ LFAN GEIECTIR ❑ SHUrNwI El 99 OTHER V.TANKESTING LEAK DETECTION 2 MANUAL `59 7 CONTINUOUS MONITORING INTERSTITIAL ❑ B SIgCONCIUATION RV a 9 MONITORINGMANUAL ❑ 0 MOGAUGING NLV TANK K ❑ gSMUNKNOWN TER O 99ING OTHER TANK TANK GAUGING TESTING 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 ❑ NO❑ SUBSTANCE REMAINING GALLONS INERTMATERIAL? THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT TANK OWNER'S NAME DAT (PRINTED 8 SIGNATURE) ^/'1 LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOAR NUMBERS BELOW 11{ COUNTY# JURISDICTION# FACILITY# TANK#00 STATE I.D:# m I I I I T77 115 IF I?Ilo 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 IkSfALLAfIONS. THIS FORM SHOULD BE ACCOMPANIED BY A PLOT PULE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE*GROUND STORAGE TANK REGULATIONS FORM B (6-95) FOP0034BR7