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STATE OF CALIFORNIA `i STATE WATER RESOURCES CONTROL BOARD b UNDERGROUND 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 CLOSED ON SI ONE REM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE :�<8 TANK REMOVED D DBA OR FACILITY NAME WHERE TANK IS INSTALLED: 05, IS74 I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A OWNERS TANK 1.D.R 3 B. MANUFACTURED BY: C. DATE INSTALLED(MOIDAYIYEAR) D. TANK CAPACITY IN GALLONS: II.TANK CONTENTS IF A-1 IS MARKED,COMPLETE ITEM C. A 1 MOTOR VEHICLE FUEL ❑ 4 OIL B.��,,,/// C, 1R REGULAR UNLEADED 3 DIESEL ❑ 6 AVIATION GAS ❑ 2 PETROLEUM ❑ BO EMPTY PRODUCT ❑ ib PREMIUM UNLEADED 4 GASAHOL ❑ 7 METHANOL ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN p WASTE ❑ Ic MIDGRADE UNLEADED ❑ 5 JET FUEL ❑ 8 M85 ❑ 2 LEADED ❑ 99 OTHER(DESCRIBE M ITEM D.BELOW) D. IF(At)IS NOT M KED, ENTER NAME OF SUBSTANCE STORED C.A S.R III. TANK CON STR TION MARK ONE ITEM ONLY IN BOXES A.B.AND C,AND ALL THAT APPLIES IN BOX D AND E A. TYPE OF ❑ 1UBLE WALL O 3 SINGLE WALL WITH EXTERIOR LINER ❑ 5 INTERNAL BLADDER SYSTEM [-] 95 UNKNOWN SYSTEM El2 S GLE WALL ❑ 4 SINGLE WALL IN A VAULT ❑ 99 OTHER B. TANK ❑ 1 BAR EL ❑ 2 STAINLESS STEEL O 3 FIBERGLASS E] 4 STEEL CLAD W/ ERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONIC F-16 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% M OL COMPATIBLE W/FRP (P"MWY Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER C.INTERIOR ❑ IRUBBER UN E::] 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING LINING OR 5 GLASS LINING ❑ 8 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER COATING IS UNING MATERIAL CO ATIBLE WITH 100% METHANOL? YES_ NO— D.EXTERIOR ❑ 1 POLYETHYLENE WR ❑ 2 COATING ❑ 3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC CORROSION PROTECTION ❑ 5 CATHODIC PROTECTIO 91 NONE 95 UNKNOWN ❑ 99 OTHER E SPILL AND OVERFILL,etc. SPILL CONTAINMENT IN ALLED(YEAR) OVERFILL PREYZNTION EQUIPMENT INSTALLED(YEAR) DROPTUBE YES_ O STRIKER PLATE YES NO DISPENSER CONTAINMENT YES NO IV.PIPING INFORMATION CIRCLE A IF ABO V GROUND OR U IF UNDERGROUND, IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION A U PRESSURE A UGRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL A U 2' UBLE WALL A 3 UNED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND A U 1 BARE STEEL A U 2 STA LESS STEEL U 3 POLYVINYL CHLORIDE(PVC)A U 4 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 6 CONC A U 7 STEEL W/COATING A U 8 100% METHANOL COMPATIBLE WIFRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHOD P TECTION A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION O i IEq QL INE IFAK a 2 UIM TIGXTNEN L]3 NfERSIIRAL 4 BECT C UN: O 5 AUTOWTIC PULP O 99 OTHER DEIEcraR tESRNG NG tFAlc DETECTOR ManIXmI V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 MANUAL ECONCIL ATIONORY 3 MONOITORIN ❑ 4 GAUGING AUTOMATIC TANK ❑ 5 MONITORINGOUND �R ❑ 8 TESTINGANNUAL ❑ 7 MONITORING INTERSTITIAL ❑ 8 SIR ❑ 9 WEEKLY MAN'GUVG L ❑10 UGING MONTHLY TANK ❑ 95 UNKNOWN ❑98 OTHER VI.TANK CLOSURE INFORMATION(PERMANENT CLO RE IN-PUCE) 1.ESTI DDA T USED R) 2.ESTM 4ED 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 DATE (PRINTED d SIGNATURE) LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY# TANK# STATE I.D.# PERMIT NUMBER PERMIT APPROVED BYIDATE PERMIT EXPIRATION DATE ci- 14-(124 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 BYA PLOT PL"' FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE I'"'ERGROUND STORAGE TANK REGULATIONS FORM (6-95) `� q-