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STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B I COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ T PERMANENTLY CLOSED ON SITE ONE ITEM F-1 2 INTERIM PERMIT F-14 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE 8 TANK REMOVED �+ DBA OR FACILITY NAME WHERE TANK IS INSTALLED: lJ I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A OWNER'S TANK I.D.R I B. MANUFACTURED BY: C. DATE INSTALLED(MOIDAYIYEAR) & 1 D. TANK CAPACITY IN GALLONS: II.TANK CONTENTS IF A-1 IS MARKED,COMPLETE ITEM C. ��•• ❑ le REGULAR UNLEADED ❑ 3 DIESEL ❑ 8 AVIATION GAS A ❑ 1 MOTOR VEHICLE FUEL4 OIL B.�/ C' ❑ 1E PREMMM UNLEADED ❑ 4 GASAHOL ❑ 7 METHANOL ❑ 2 PETROLEUM ❑ 80 EMPTY 175E 1 PRODUCT ❑ is MDGRADE UNLEADED ❑ 5 JET FUEL ❑ 8 M85 ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN �❑ 2 WASTE ❑ 2 LEADED ❑ 99 OTHER(DESCRIBE N ITEM 0.BELOM D. IF(A1)IS NOT MARKED. ENTER NAME OF SUBSTANCE STORED NQ m F C.A.S.M III. TANK CONSTRUCTIO MARK ONE ITEM ONLY IN BOXES A.B.AND C,AND ALLTHAT A LIES IN BOX D AND E A. TYPE OF ❑ I DOUBLE W ❑ 3 SINGLE WALL WITH EXTERIOR ER ❑ 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 CUD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE 8 POLYVINYL CHILD E ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP (Primary Tank) ❑ 9 BRONZE ❑ GALVANIZE EEL ❑ 95 UNKNOWN ❑ 99 OTHER C.INTERIOR ❑ I RUBBER UNED ❑ 2 AL ING ❑ 3 EPDXY LINING E:] 4 PHENOLIC LINING LINING OR ❑ 5 GLASS LINING ❑ 6 UN ED ❑ 95 UNKNOWN ❑ 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH b METHAN 7 YES_ NO_ D.EXTERIOR ❑ 1 POLYETHYLENE WRAP 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC CORROSION 91 NONE 95 UNKNOWN ❑ 99 OTHER PROTECTION ❑ 5 CATHODIC PROTECTION SPILLCONTAINME NSTALLED(YEAR) O RRLL PREVENRON EQUIPMENT INSTALLED (YEAR) E.SPILL AND OVERFILL,QTc. DROP TUBE YES NO_ STRIKER PLATE YE NO_ DISPENSER CONTAINMENT YES_ NO IV.PIPING INFORMATION C14 A IF ABOVE GROUND OR U IF UNDERGROUND,B HIF APPLICABLE A. SYSTEM TYPE A U I SUCT A U 2 PRESSURE A U 3 GRA A U 4 FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION A U 1 Si LE WALL A U Z DOUBLE WALL A U 3 LINED TR CH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND A U '/ME E STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL C RIDE(PI C. U 4 FIBERGLASS PIPE CORROSION A U ALUMINUM A U 6 CONCRETE A U 7 STEEL W/COATING A U 8 100% METHANOL COMPATIBLE WWRP PROTECTION A 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER 1 IRCIMNIGLL INE IFA" 2 UNE TX9ma35 3 L NUWS I"fERSLInAL 4 EIECRWIAC UNE 5 AMOW=MW ORIER D. LEAK DETECTION 9 vm ❑ lesnxa ❑ uoxrtoNN6 ❑ tEA"1>ET om 9en m ❑ V.TANK LEAK qtECTION ❑ 1 VISUAL HECK ❑ 2 MANUAL RECONCI INVENTORYIATION ❑ 3 MOTORING ❑ 4 GAUGING AUTOMATIC TANK GROUND WATER ❑ 6 ANNUAGTANK ❑ T NON TORING INTERSTITIAL ❑ e SIR ❑ 9 WE GAUGINGMAL ❑10 MO TTHLY TANK ❑ g UNKNOWN NG ❑99 OTHER VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PUCE) ^ , 1.ESTIMATED DATE T USED( ) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED VATH YES O NO _ SUBSTANCE REMAINING GALLONS INERTMATERIAL7 'EL 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 4 MONATURE) LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY a JURISDICTION M FACILITY a TANK N STATE I.D.# 6 PERMIT NUMBER PERMIT APPROVED BYIDATE PERMIT EXPIRATION DATE 1 1 7k I dr,Co/4 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 P ' FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE .IERGROUND STORAGE TANK REGULATIONS FORM 8 (6-95) `i 1--e- ot_ [G 8