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STATE OF CALIFORNIA "`.o",�r o , STATE WATER RESOURCES CONTROL BOARD o UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B _ . .i I COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ON SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED G DBA OR FACILITY NAME WHERE TANK IS INSTALLED: '33a -/Tj4q &4A 4GD'r I. TANK DESCRIPTION COMPLETE ALL ITEMS— SPECIFY IF UNKNOWN A OWNER'S TANK I.D.# / B. MANUFACTURED BY: v C. DATE INSTALLED(MO/DAYNEAR) v. k'" D. TANK CAPACITY IN GALLONS: �0 ILTANK CONTENTS IFA-1 IS MARKED,COMPLETE ITEM C, A MOTOR VEHICLE FUEL ❑ 4 OIL B. C. ❑ 1a REGULAR UNLEADED 3 DIESEL ❑ 6 AVIATION GAS 2 PETROLEUM ❑ SO EMPTY 1 PRODUCT ❑ 1D PREMIUM UNLEADED 4 GASAHOL ❑ 7 METHANOL 8 M85 E:] 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN 2 WASTE O 2G LEADED UNLEADED ❑❑ 9 J 9OTHER(DESCRET FUELIBE IN ITEM D.BELONG D. IF(A1)IS NOT MARKED. ENTER NAME OF SUBSTANCE STORED C.A S.#: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN 13OXESA,B.AND C,AND ALL THAT APPLIES IN BOX D AND A. TYPE OF ❑ 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 5 INTERNAL BLADDER SYSTEMM5 UNKNOWN SYSTEM [—] 2 SINGLE WALL F--14 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 ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL 95 UNKNOWN ❑ 99 OTHER C.INTERIOR ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING LINING OR ❑ 5 GLASS LINING ❑ 6 UNLINED ES45 UNKNOWN ❑ 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? Y S— NO— D.EXTERIOR ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC CORROSION PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE 5 UNKNOWN ❑ 99 OTHER E.SPILL AND OVERFILL,etc. 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 A. SYSTEM TYPE A 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION A U I SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH 95 UNKNOWN A U 99 OTHER C. MATERIAL AND A U / BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A U 4 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL W/COATING A U 8 100% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION UNKNOWN A U 99 OTHER D. LEAK DETECTIONI WGIOMM UNE LEvc 2 UNE TIGNTr M 3 00IMN000S MIERST 4 EU:CM MC UK 5 Au llc Pure ❑ O CMR ❑ TESTNG ❑ M WMWG ❑ LEAN OEIECT011 ❑ SHUf00YM ❑ 99 DTHm V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK 2 RECONCILIATIOMANUAL N MONITORING ❑ 3 VADMONITORING ❑ 4 AUTOMATGAUGING MONITORING TANK ❑ 5 GROUND MONTORINGTER TESTING ❑ 7 MONITORING INTERSTITIAL 8 SIR ❑ 9 ANK GAUGINGAL ❑ 10 TES ST TANK ❑ 95 UNKNOWN 99 OTHER VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) 1.ESTIMATED DATE LAST ED( ) 2.ESTIMATED QUANTITY SUBSTANCE REMAINING GF O 3.WAS TANK FILLED WITH YES ❑ NO❑ II 1L f' GALLONS INERT MATERIAL? THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE IS TRUE AND CORRECT L TANK OWNER'S NAME DATE (PRINTED a SIGNATORET LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY# TANK# q STATE I.D.# y L 6 '1 � 1y ERM PERMIT NUMBER PERMIT APPROVED BY/DATE PIT EX4 TION DATE THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. FORT''MUST BE COMPLETED FOR INSTALLATIONS. THIS FORM SHOULD BE ACCOMPANIED BY A PLOT PU LE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE I. 'GROUND STORAGE TANK REGULATIONS FORM B (6-95) L� ,�