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STATE OF CALIFORNIA 0 STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM, ❑ ❑ 7 PERMANENTLY CLOSED ON SITE MARK O;FACILITY ❑ 7 NEW PERMIT 3 RENEWAL PERMIT ❑ 5 GRANGE OF INFORMATION ONE IT ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 6 TANK REMOVED } DBA OR NAME WHERE TANK IS INSTALLED: i ' I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN B. MANUFACTURED BY: -»+ I Ar– A OWNER'S TANK I.D.# D. TANK CAPACITY IN GALLONS: C. DATE INSTALLED(MOICAYNEAR) r c- ---------------- II.TANK CONTENTS IF A-1 IS MARKED,COMPLETE ITEM C. ❑ la REGULAR UNLEADED 3 DIESEL ❑ 6 AVIATION GAS r7D ❑ 4 OIL R. C. 1 MOTOR VEHICLE FUEL ❑ 1b PREMIUM UNLEADED 4 GASAHOL ❑ 7 METHANOL 2 PETROLEUM ❑ 60 EMPTY �y 1 PRODUCT ❑ 1c MIDGRADE UNLEAD€D ❑ 5 JET FUEL ❑ 6 M65 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED ❑ 99 OTHER(DESDRIBE IN ITEM D.BELDWIC.A.S.N: F{A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED III, TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A,B,AND C,AND ALL THAT APPLIES IN BOX 0 AND E '? 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 5 INTERNAL BLADDER SYSTEM ❑ 95 UNKNOWN [EXTERIOR F ❑ ❑ 99 OTHER M ❑ 2 SINGLE WALL 4 SINGLE WALL IN A VAULT 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS 4 STEEL CLAD W!FIBERGLASS REINFORCED PLASTIC K ❑ 5 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 6 1D11°6 METHANOL COMPATIBLEWIFRP IAL ❑ s CONCRETE Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING OR �,, 6 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER OR ❑ 5 GLASS LINING I NG IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES NO— COATING ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC CORROSION 91 NONE ❑95 UNKNOWN ❑ 99 OTHER PROTECTION 5 CATHODIC PROTECTION ❑ f SPILL GON7AINM1AE.. INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) E.SPILL AND OVERFILL,CtC, pRpp 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 A. SYSTEM TYPE A U 1 SUCTION A U` PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND A U 1 BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) FIBERGLASS PIPE U CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL W/COATING A U B 100% METHANOL COMPATIBLE W1FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER 1 MECHANICAL LINE LEAK ❑2 UNE TIGHTNESS ❑3 CONTINUOUS 1NYERSTITIAL ❑4 ELECTRONIC LINE ❑5 AUTOFAATIC PUMP ❑ 99 OTHER D, LEAK DETECTION ❑ TESTING MONITORING LEAK DETECTOR SHUTDOWN 9ETECTDR V.TANK LEAK DETECTION['Tso CONTTINUOOUUSS 2 MANUAL INVENTORY 3 VACOZE MNU 4 AUTOMATIC TANK 5 GROUND WATEE996 ANNUAL TANK ❑ 1 VISUAL CHECK RECONCILIATION MONITORING GAUGING MONITORINGTESTING 7 MONITOR NG INTERSTITIAL ❑ 8 BIR ❑ 9 T1ANK GAUGANGAL ❑ 10 TOTING TANK ❑ 95 UNKNOWN OTHER VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE SN-PLACE) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES E] NO❑ 1.ESTIMATED DATE LAST USED(MOIDAYlYR) SUBSTANCE REMAINING GALLONS INERT MATERIAL? THIS FORM HAS SEEN COMPLETED U'N'DER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT =OWNER'SAME E) LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY 4 JURISDICTION 4 FACILITY H TANK# STATE I.D.# PERMIT APPROVED BYIDATE PERMIT EXPIRATION DATE PERMIT NUMBER _ MUST BE COMPLETED FOR THIS FORM-9MUST BE ACCOMPANIED BY A SHOULD BE ACCOMPANIED BY AIP OT OIC T10 ILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING FILED.-FORM A.UNLESS A CURRENT FORM A HAS BEEN FORM RGROUND STORAGE TANK REGULATIONSNS. THIS FORM FORM B {6-95)