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STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD • "c UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B I COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ONSITE ONE REM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK ISINSTALLED vT 1 C L/ I. TANK DESCRIPTION COMPLETE ALL ITEMS'SPECIFY IF UNKNOWN A OWNER'S TANK I.D.N B. MANUFACTURED BY: C. DATE INSTALLED(MQIDAY/YEAR) .�X. t�olEmNp 1Q95 D. TANK CAPACITY IN GALLONS: 7 II.TANK CONTENTS IFA-1 IS MARKED,COMPLETE ITEM C. Al MOTOR VEHICLE FUEL ❑ 4 OIL B. C ❑ to REGULAR UNLEADED ❑ 3 DIESEL ❑ 6 AVIATIONGAS ❑ 2 PETROLEUM ❑ W EMPTY 1 PRODUCT 1b PREMIUM UNLEADED E:] 4 GI E] 7 METHANOL ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 1 WASTE TO MIDGRADE UNLEADED ❑ 5 JET FUEL ❑ 8M85 ❑ 2 LEADED ❑ 99 OTHER(DESCRIBE IN REM D.BELONG D. IF(AA)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S.N: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A B,AND C,AND ALL THAT APPLIES IN BOX D AND E A. TYPE OF >I5;1_1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 5 INTERNAL BLADDER SYSTEM SYSTEM ❑ 2 SINGLE WALL ❑ ❑ 95 UNKNOWN SINGLE WALL IN A VAULT ❑ 99 OTHER B. TANK ❑ 1 BARE STEEL ❑ 2 STAINLESS STEEL �3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP (PHIRAry 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 '.r5f3 5 GLASS UNING ❑ 6 UNLINED ❑ 95� UNKNOWN ❑ 99 OTHER \ COATING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES d NO_ D.EXTERIOR ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING CORROSION ❑ 3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE E:195 UNKNOWN ❑ 99 OTHER E.SPILL AND OVERFILL,ate. SPILL CONTAINMENT INSTALLED(YEAR) i / OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) DROP TUBE YES NO_ STRIKER PLATE YES_ No DISPENSER CONTAINMENT YES _L IV.PIPING INFORMATION NO_ CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION A®2 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL A 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)A6 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 A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION M aollAL LIRE LEAN ❑2 LNS�W:SS ❑3 S IXiFg5T11AL ❑4�N 9E1EC10R ❑5 Z-`'u— ❑ 99 OhIER OLIECfOR V.TANK LEAK DETECTION yy❑.,x1 VISUAL CHECK ❑ 2 MANUAL INV VENTION RY JE] 3 MOORING 4 AUTOMAGAUGINTIC TANK ❑ 5 GROUND WATER 6 ANNUALTANK NG 7 MON TORNG N US INTERSTITIAL ❑ 8 Slfl ❑ 9 WEEKLY GAUGING El❑ 10 TESTINGY TANK ❑ 95MUNKNOWN ❑99 OTHING ER I.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) 1.E>A MD DATE LAST USED(MO/DAY/Y 2.ESNMATED ITY OF 3.WAS TANK FILL H SUBST E REMAINING ONS INERT MA IAL 7 YES ❑ NO THIS FORM HAS BEEN COMPLETED UNDER P A OF PERJ ADT EST OF MY KNOWLEDGE,IS TRUE AND CORRECT TANK OWNER'S NAME (PRINTED d SIGNANRE) Y DATE LOCAL AGENCY USE ONLY THE STATE I. .NUMBER I POSED OF THE FOUR NUMBERS BELOW COUNTY a JURISDICTION N FACILITY A1�377 TANK N Q STATE LD:# m = 3 Q K=Jl3 124 PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED, FORM C MUST BE COMPLETED FOR INSTALLATIONS. THIS FORM FORM B (8-95)SHOULD BE ACCOMPANIED BY A PLOT PUWLE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE GROUND STORAGE TANK REGULATIONS