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STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD s d� UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B 1 COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ONE REM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE 8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: Q I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A OWNERS TANK I.D.# B. MANUFACTURED BY: -� C. DATE INSTALLED(MO/DAY/YEAR) D. TANK CAPACITY IN GALLONS: o D II.TANK CONTENTS IF A-1 IS MARKED,COMPLETE ITEM C. A 1 MOTOR VEHICLE FUEL ❑ 4 OIL 8. C. ❑ to REGULM UNLEAOm 3 DIESEL ❑ 6 AVIATION GAS ❑ 2 PETROLEUM ❑ BO EMPTY �1 PRODUCT ❑ 1b PREMUM UNLEADED 4 GASAHOL ❑ 7 METHANOL ❑ 1c MIDGRADE UNLEADED ❑ 5 JETFUEL ❑ 8 MES ❑ 3 CHEMICAL PRODUCT O 95 UNKNOWN ❑ 2 ASTE ❑ 2 LEADED O 99 OTHER(DESCRIBE IN ITEM D.BELON1 D. IF(Al)IS NOT MARKED. ENTER NAME OF SUBSTANCE STORED C.A S.e III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A B,AN C,AND ALL THAT APPLIES IN BOX D AND A. TYPE OF ❑ i DOUBLE WALL ❑ 3 SINGLE WA TH EXTERIOR UNER ❑ 5 INTERNAL BLADDER SYSTEM [—] 95 UNKNOWN SYSTEM 2 SINGLE WALL ❑ 4 SINGLE W IN A VAULT E] 99 OTHER S. TANK X1 BARE STEEL ❑ 2STAINLE STEEL ❑ 3 FIBERGLASS O 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE O 6 POLWI L CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP (PTimmy Tank ❑ 9 BRONZE O 10 GAL NRED STEEL O 95 UNKNOWN O 99 OTHER C.INTERIOR ❑ 1 RUBBER LINED a 2 A D UNING ❑ 3 EPDXY LINING O 4 PHENOLIC LINING LINING OR ❑ 5 GLASS LININGS LINED ❑ 95 UNKNOWN ❑ 99 OTHER COATING IS UNING MATERIAL COMPATIBLE WITH METHANOL? YES_ NO,�e D.EXTERIOR ❑ 1 POLYETHYLENE WRAP O COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC CORROSION PROTECTION ❑ 5 CATHODIC PROTECTION 91 NONE ❑95 UNKNOWN O 99 OTHER E.SPILL AND OVERFILL,etc. SPILL CONTAINMENT IN ALLED(YEAR) OVERFILL PREVENIPMENT INSTALLED(YEAR) DROP TUBE YES NO STRIKER PLATE YES_ NOTI EQUDISPENSER CONTAINMENT YES_ NO IV.PIPING INFORMATION CIRCLE A 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 B. CONSTRUCTION A 1 SINGLE!AV A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND Ao 1 BARESTE A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A U 4 FIBERGLASS PIPE CORROSION A U 5 ALUM INU A U 6 CONCRETE A U 7 STEEL W/COATING A U 8 1DO% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALV 2ED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION Nr MECNNa INE UAK 2 WE TIEWME3 CCNINIIWS NI 3 EFNI R 4 EIECIRONIC IN [:]E 5 AIT = 99 OTHER PIMP CETECf L] TESTN9 ❑ aONTd LEAN DETEMOA 9Nf00WN ❑ V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 RECONCILIATION CILIATIONUAL ORY ❑ 3 VADOZEMONITORING ❑ 4 AUTOMATIGAUGING MONITORING TANK ❑ 5 GROUNDWAMONTORING�R F7 TESTING E] NUAL ❑ 7 MONITORING CONTINUOUS INTERSTITIAL O B SIR O 9 VTIAENKLA MANGAL E:]10 TEOSNnTNHGY TANK ❑ 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PUCE) 1.ESTIDATE T USED R) 2 ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH VES ❑ 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 OWNERS NAME DATE (' RW 431W TUR') LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER 15 COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION It FACILITY k TANK# STATE I.D:# PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. FORM C MUST BE COMPLETED FOR INSTALLATIONS. THIS FORM SHOULD BE ACCOMPANIED BY A PLOT PLY' FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THU E ""7RGROUND STORAGE TANK REGULATIONS 9- LE FORM B (6-95) �i �— / 1rX' - L/