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STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD •"w c UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B "� COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM, in MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 P QOSED ON ONE ITEM ❑ 2 INTERIM PERMIT ❑ 6 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 9 ,T 1� 0 ED) DBA OR FACILITY NAME WHERE TANK IS INSTALLED: L av / I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A OWNER'S TANK 1.0.t ( B. MANUFACTURED BY: C. DATE INSTALLED(MCfMAWYEAR) J 0. TANK CAPACITY IN GALLONS: /}]}D II.TANK CONTENTS IF A-1 IS MARKED,COMPLETE ITEM C. v A. / MOTOR VEHICLE FUEL ❑ a OIL B, a to REGULAR UNLEADED 3 DIESEL ❑ 6 AVIATION GAS ❑ 2 PETROLEUM ❑ 80 EMPTY - 1 PRODUCT 10 PREMIUM UNLEIOE] 6 GASAHOL 7 METHANOL ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE Ic MOGRADE UNLEADED (� 5 JET FUEL B M85 ❑ 2 LEADED a 99 OTHER(DESCRIBE N ITEM 0.BELOW) 0. IF(At)IS NOT MARKED. ENTER NAME OF SUBSTANCE STORED C.A S.• III. TANK CONSTRUCTION MARK ONE REM ONLY IN BOXES A.B.AND C,AND ALL THAT APPLIES IN BOX D AND E A. TYPE OF ❑ 1 DOUBLE WALL ❑ 3 SINGLE WALL VATH EXTERIOR LINER ❑ 5 INTERNAL BLADDER SYSTEM ❑ 95 UNKNOWN SYSTEM ❑ 2 SINGLE WALL ❑ 6 SINGLE WALL IN A VAULT ❑ 99 OTHER S. TANK ❑ I BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ d STEEL CUD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 3 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ B 100% METHANOL COMPATIBLE W/FRP (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANREO STEEL ❑ 95 UNKNOWN ❑ 0 OTHER C.INTERIOR ❑ 1 RUBBER UNED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ A PHENOLIC LINING LINING OR ❑ 5 GLASS UNING ❑ 8 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER COATING IS UNING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO— D. O_D CORROSION I ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ d FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER E SPILL AND OVERFILL,eta SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) DROP TUBE YES_ NO_ STRIKER PLATE YES_ NO_ DISPENSER CONTAINMENT YES_ NO IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND.BOTH IF APPLICABLE =DETrECnON PE A U I SUCTION A U 2 PRESSURE A U 3 GRAVITY A U s FLEXIBLE PIPING A U 99 OTHER TION A U I SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER AND A U 1 BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE WVC)A U A FIBERGLASS PIPE N A U 5 ALUMINUM A U a CONCRETE A U 7 STEEL W/COATING A U B 100% METHANOL COMPATIBLEW/FRP N A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER CTION 1 11EO1"''A IaK LEut ❑2 LNE 11a111F_53 ❑3 cwnMtoufi NlrnsnlML ❑a OECRaNO uraE ❑s AvrdMTN RWF OEIEGTOR TESIaIa 1pMaRe,G UAK(EITMR 9KmbaN ❑ 99 OTHESL V.TANK LEAK DETECTION F-R- CHE 7 CONTINUOUS INTERSTfiIAL ❑ 2RECONCILIATIONMANIJAL ORY ❑ 3 TORING ❑ AGAUD HG C TANK ❑3 MONITORINGROUND G ❑ 6 TE$TINGMONITORING ❑ 8 SIR ❑ 9 TANKxGAUG NGAL ❑ 10 MONTHLY TANK ❑ 93 UNKNOWN ❑ 99 OTHER TESTING VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) I.ESTIMATED DATE LAST USED(MO/DAY/YR) ( 2.ESTIMATED OUANTTTY OF 1 WAS TANK FlLLED WITH ,ES ❑ NO ❑ SUB STANCEREMAINING GALLONS I IN MATERIAL THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUEAND CORRECT TANK OIGWNER'S NAME DATE IYRMTEJ 6 SNATLRE) LOCAL AGENCY USE ONLY THE STATE LD.NUMBER IS COMPOSED OFTHE FOUR NUMBERS BELOW .7 COUNTY a JUTRISDIC�TION a FACILITY t TANK R v STATE I.DJ K� PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE ! / 71 ' THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A UNLESS A CURRENT FORMA HAS BEEN FILED. FORM CMUST BE COMPLETED FOR INSTALLATION41H15 FORM SHOULD BE ACCOMPANIED BY A PLOT PI THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE I- - 7UNO STORAGE TANK REGULATIONS FORM B (60.5) �. �.. �t— fRTpaalA9A/