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0 STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B m COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. r MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION 7 PER CLOSED ON SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE ❑ — 8 TANK REMOVED )I DSA OR FACILITY NAME WHERE TANK 1S INSTALLED: ir, I. TANK DESCRIPTION COMPLETE ALL ITEMS— SPECIFY IF UNKNOWN A- OWNER'S TANK I.D.# � B. MANUFACTURED BY: C. DATE INSTALLED(MO/DAY/YEAR) TSS D. TANK CAPACITY IN GALLONS: / Zy D07„7 II.TANK CONTENTS IF A-1 IS MARKED,COMPLETE ITEM C. --------------------- A �'r'1 MOTOR VEHICLE FUEL 4 OIL B C �7c a REGULAR UNLEADED 3 DIESEL 6 AVIATION GAS 2 PETROLEUM ❑ 80 EMPTY 1 PRODUCT b PREMIUM UNLEADED 4 GASAHOL ❑ 7 METHANOL3 CHEMICAL PRODUCT 95 UNKNOWN ❑ 2 WASTE MIDGRADE UNLEADED 5 3ET FUEL ❑ 8 M85 ❑ 2 LEADED 99 OTHER(DESCRIBE IN ITEM D.BELOW) D. IF[A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S.# III, TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A,B,AND C,AND ALL THAT APPLIES IN BOX D AND E FA. TYPEOF 1 DOUBLE WALL3 SINGLE WALL WITH EXTERIOR LINER ❑ 5 INTERNAL BLADDER SYSTEM ❑ 95 UNKNOWN M 2 SINGLE WALL ❑ 4 SINGLE WALL IN A VAULT ❑ 99 OTHER K 1 BARE STEEL2 STAINLESS STEEL ❑ 3 FIBERGLASS � 4 STEEL CLAD W /FIBERGLASSREINFORCED PLASTIC IAL ❑ 5 CONCRETE 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP (Primary Tank) ❑ y BRONZE � 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER C.INTERIOR ❑ 1 RUBBER LINE(] 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 100°1. METHANOL? YES—Y`^NO_ D.EXTERIOR ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING CORROSION ❑ 3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER E.SPILL AND OVERFILL etc. SPILL CONTALNMENT,II�$TALLEO(YEAR) OVERFI P.FIEVENTION EpUIPMENT INSTALLED(YEAR) DROP TUBE YES °'? NQ STRIKER PLATE YES +� NQ DISPENSER CONTAINMENT YES NO 1. IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION A ill PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER B, CONSTRUCTION A U 1 SINGLE WALL A (1 DOUBLE WALL A U 3 LINED TRENCH A U 95 eU:NKNOWN A U 99 OTHER C. MATERIAL AND A U 1 BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVCJ A u�ax FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL W/COATING A U B 100% METHANOL COMPATIBLE WJFRP PROTECTION A U 9 GALVANIZED ST�r. A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION a 1 ME...'.' IECH MI.UNE LEAK LINE TIGHTNESS CONTINUOUS INTERSTMAL ❑4 ELECTRONIC LINE f-=a7_$"ALROMATIC PUMP DETECTOR. TESTING MONITORPNG LEAK DETECTOR L SHUTDOWN ❑ 99 OTHER V.TANK LEAK DETECTIONli3 / ❑ 1 VISUAL CHECK ❑ 2 RECONCILIATIONMANUAL IORY ❑ 3 MONIITORING 4GROUND 7 GAUGNGIC TANK ❑ 5 MQNTORiNGTER ❑ 6 TESTfNGTANK MON TOR G INTERSTITIAL ❑ 6 SIR ❑ 9 WEEKLY MANUAL ❑ 95 UNKNOWN 10 MONTHLY TANK ❑ TANKGAUGING TESTING 99 OTHER VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE 1.ESTIMATED DATE LAST USED(MO/DAY/YRy 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH SUBSTANCE REMAINING GALLONS INERT MATERIAL 7 YES ❑ NO ❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT TANK OWNER'S NAME (PRINTED d SIGNATURE( DATE LOCAL AGENCY USE ONLY THE STATE 1.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY# TANK# ' LPFn1IT TATE l.D.# ❑� I�� ,.� ,�, -:�' �.,� , �� RPERMIT APPROVED BYlDATE PERMIT EXPIRATION DATE THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLIC ON-FOAM A,UNLESS A CURRENT FORMA HAS BEEN FILED. PO C MUST BE COMPLETED FOR INSTALLATIONS. FORM B (6-95) SHOULD BE ACCOMPANIED BY A PLOT PI VILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THEORGROUND STORAGE TANK REGULATIONS