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STATE OF CALIFORNIA u�a, u•,e yr STATE WATER RESOURCES CONTROL BOARD _ UNDERGROUND STORAGE TANK PERMIT APPLICATION -CORM B COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. ❑ 7 PERMANENTLY CLOSED ON SITE 5 CHANGE OF INFORMATION 8 TANK REMOVED 3 RENEWAL PERMIT 6 TEMPORARY TANK CLOSURE El ONLY t NEW PERMIT L❑J A AMENDED PERMIT < Ie 2 INTERIM PERMITISL�'1, f7 stn-r-N��✓ ONE ITEM ❑ C FAM 11. l Y rrl�i DBA OR FACILITY NAME WHERE TANK IS INSTALLED; SP IF UNKNOWN I, TANK DESCRIPTION COMPLETE ALL ITEMS- B, MANUFACTURED BY: SC' A pWWER'S TANK J.D.R � D. TANK CAPACITY IN GALLONS: C. DATE INSTALLED( I Z '�Do +C I°I 4'� MOIDAY/YEAR) ��IV�i ❑ 6 AVIATION GAS 1F A-i IS MARKED,COMPLETE ITEM C. 1a REGULAR UNLFJIDED 3 DIESEL ❑ 7 METHANOL H.TANK CONTENTS 4 GASAWOL VEHICLE FUEL ❑ C. lb PREMIUM UNLEADED ❑ 4 OIL B. El is MIDGRADE UNLEADED ❑ 5 JET FUEL ❑ B MBS 1 MOTOR 1 PRODUCT A. 80 EMPTY ❑ 99 DTHER(DESCRIBE SN ITEM D.BELD'M ❑ 2 PETROLEUM ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED 3 CHEMICAL PRODUCT 11C.A.S. D. NAME OF SUBSTANCE STORED IF{A.1}IS NOT MARKED, ENTER ❑ Ill. TANK CONSTRUCTION MARK ONE ITEM ONLYGLIN BOXES A.B,AND C,AND ALL THAT APPLIES IN BOX D AND INTERNAL BLADDER SYSTEM El 95 UNKNOWN ❑ E WALL WITH AUL5 1 DOUBLE WALL 3 SINdR LINER ❑ gg OTHER El A. TYPE OF O 2 SINGLE WALL 4 SINGLE WALL IN A VAULT T SYSTEM ❑ 3 FIBERGLASS � 4 STEEL CLAD WI FIBERGLASS REINFORCED PLASTIC ❑ t BARE STEEL ❑ 2 STAINLESS STEEL❑ B 1()0% METHANOL COMPATIBLE WIFRP B. TANK 6 POLYVINYL CHLORIDE 7 ALUMINUM � 99 OTHER MATERIAL ❑ 5 CONCRETE 95 UNKNOWN (primary Tank) ❑ g BRONZE ❑ 10 GALVAN4ZED STEEL 3 EPDXY LINING ❑ ; p}9ENOLSC LINING El2 ALKYD LINING ❑ b—y 99 OTHER ❑ t RUBBER LINED ❑ 95 UNKNOWN U C.INTERIORDR-B UNLINED LINING OR ❑ 5 GLASS LINING METWANOL7 YESX NO— COATING IS LINING MATERIAL COMPATIBLE WITH 160°: �4 FIBERGLASS REINFORCED PLASTIC 2 COATING ❑ 3 VINYL WRAP D,EXTERIOR ❑ 1 POLYETHYLENE WRAP ❑95 UNKNOWN ❑ 99 OTHER CORROSION 91 "ONE ❑ 5 CATWODIC PROTECTION OVERFILL PREVENTION EQUIPMENT SNIT NO PROTECTION Np DISPENSER CONTAINMENT YES SPILL CONTAINMENT INSTANO D{YEAR) STRIKER PLATE YES E.SPILL AND OVERFILL,etc. DROP TUBE YES IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND'BOTH IF APPLICABLE A U a FLExIB'�PIPING A U 99 OTHER A U t SUCTION A U 2 PRESSURE A U 3 GRAVITY A. SYSTEM TYPE 3 LINED TRENCH A U 95 UNKNOWN A U 99 (?THEA B. CONSTRUCTION A U 1 SINGLE WALL A U 2 DOUBLE WALL A U 1 A U 2 STAINL€SS STEEL A U 3 POLYVINYL CHLORI A U BARE STEEL DE(PVC)A U B f76' METHANOL COMPATIBLE W1FRP C. MATERIAL AND A U 6 CONCRETE A U 7 STEEL W/COATING CORROSION A U 5 ALUMINUM 95 UNKNOWN A U 99 OTHER 10 CATHODIC PROTECTION A U 4 t3 u AIn6MAT"'P PROTECTION A U 9 GALVANIZED STEEL A U SHut )WN 9g ETHER UNE TIGHTNESS LEAK t7E1`EC"c>I+ SAECHANICAL LINE LEW TESTING WOMT0RRif' D. LEAK DETECTION � DETECTOR V.TANK LEAK DETECTION 4 AUTCoAATIC TANK ❑ 5 GRC+ .D WATER ❑6 ANNUALTANK GAUGING M04':'CNG TESTING ❑ 2 RECONCILIATIONMANUAL ORY ❑ 9 WEEKLY IL ❑ ❑ i VISUAL CHECK 10 MONTHLY TAMC ❑ 95 UNK'VCV�N ❑99 OTHER 7 CONTINUOUS INTERSTITIAL ❑ 9 SIR ❑ TANK GAUGING TESTING MONITORING , , VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) f 3 wASTANK FILLED VA_^ -SCS L7] NO❑ �, 2.ESTIMATED QUANTITY OF GALLONS INERT MATERIAL 1,ESTIMATED DATE LAST USED(MO DAYIYR) SUBSTANCE REMAINING THIS FORM.HAS BEEN C MPLE ED NDER PENALTY OF PERJURY,AND 70 THE BDATE OF MY KNOWLEDGE,IS TRUE AND N�D�ORFtEC TANKOWNER' NAME [PRINTED 8 SIGN Tt1REL LOCAL AGENCY LY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW4- UMBTRS#BELOW TANK# COUNTY# JURISDICTION# D N ��,- r STATE LD:# PERMIT EXPIRATION DATAT E PERMIT APPROVED BYIDATE PERMIT NUMBER MUST BE COMPLETED FOR THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATIONLE TOHRIS ORM W TH THE LOCAL AGENCY 1MPLE EEN FILED. FORM C GROUND STORAGE TANK RNSTALL}OTIONS.THLF SHOULD BE ACCOMPANIED BY A PLOT PLf FORM 0 (6-95)