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STATE OF CALIFORNIA .dam, ",a a° 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 ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION 8 TANK REMOVED 1 NEW PERMIT d AMENDED PERMIT 6 TEMPORARY TANK CLOSURE MARK ONLY ❑ 2 INTERIM PERMIT ❑ ONE REM ❑ ]A� Wf5 l-E,Ma•J DBA OR FACILITY NAME WHERE TANK IS INSTALLED: SlAEu-SEmJLA.G I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN B MANUFACTURED BY: mW A OWNER'S TANK I.D.Y D. TANK CAPACITY IN GALLONS I Q d C. DATE INSTALLED(MOIDAY/YEAR) II.TANK CONTENTS IF A-1 IS MARKED,COMPLETE ITEM C. 8 AVIATION GAS �p to REGUUfl UTAEADED ❑ 3 DIESEL ® 1 MOTOR VEHICLE FUEL ❑ d OIL B. C ❑ 1b PREMIUM UMFI�DED ❑ 4 GASAHOL ❑ 7 METHANOL �` ❑ 80 EMPTY 111 PRODUCT El MNIGRADE UNLEADED ❑ 5 JET FUEL ❑ 8 M65 ❑ 3 PETROLEUM 95 UNKNOWN 112 WASTE ❑ 2 LEADED ❑ 99 OTHFA(DESCRIBE IN REM D.BELOW) ❑ 3 CHEMICAL PRODUCT ElC.A.S.N D. IF(At)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED II. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.B,AND C,AND ALL THAT APPLIES IN BOX D AND E III TYPE K 11 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 5 INTERNAL BLADDER SYSTEM © KN 95 UNOWN 99 OTHER SYSTEM ❑ 2 SINGLE WALL ❑ 4 SINGLE WALL IN A VAULT ❑ 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS E] 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B. TANK ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP MATERIAL ❑ 5 CONCRETE (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL 95 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING E] 3 EPDXY LINING 4 PHENOLIC LINING C.INTERIOR ❑ 6 UNUNED ® 95 UNKNOWN E] 99 OTHER LINING OR ❑ s GLASS LINING COATING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES— NO— D.EXTERIOR ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC CORROSION91 NONE ©95 UNKNOWN ❑ 99 OTHER PROTECTION ❑ 5 CATHODIC TON ❑ SPILLCONTAIN TAINMENT INSTALLED(YEAR)1`^P"a44M OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) E SPILL AND OVERFILL,BLC. DROP TUBE YES_ NO STRIKER PLATE VES_ 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 a 2 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 O 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)A U 6 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 6 CONCRETEA 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 95 UNKNOWN A U 99 OTHER t MEGMINGLL LNIE 1FNI 2 lWE iXJnNE55 7 CDNTIXV9U5 MFRS1nIK 4 BEC111014C UN: 5 AVfoYAnG PUMP D. LEAK DETECTION ❑ 9RD6 ❑ 1ESTNK ❑ MONraRnrG ❑ L&x c6lEcroR 9AI100WN ®99 OTHER UN11r.unI.I.1 V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 RECONCILIATION MONITORING ❑ 3 MONOITORING ❑ 4 GAUGAUTOING C TMA( ❑ 6 MON TORINGGROUND 7� ❑ 6 TESTINGANNUALTANK ❑ 7 MON TOR U INTERSTITIAL ❑ 8 SIR ❑ 9 WEEKLY MANING L ❑10 TMEOSt HLY TANG � 95 UNKNOWN ❑99 OTHER VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PUCE) 1.ESTIMATED DA US USEpD(M�{O/DAY/YR) 2 ESTMA7ED QUANTITY OF 3.WAS TANK FlLLEO WITH AQ(lD� y�/ I 10.3 SUBSTANCE REMAINING GILLONS W m MATEP\h l !� I THIS FORM HAS BEEN COMPLETED UNDER AL OF RJURY, TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT TANK OWNER'S NAM F;V— DATE (PRINTED 8 SIGNATURE) !_ I I'fkM If � ,p LOCAL AGENCY USE ONLY THESTATEI MBRVS COMPOSED OF THE FOUR NUMBERS BELOW co6NTY# JURISDICTION# FACILITY#]'77v TANK# OCi' STATE I.D1 FF = 1�131 I h I I (c PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT IXPNATiOi PZA7E L CI THIS FORM MUST BE ACCOMPANIED BYAPERMIT APPIJCATION MA,UNLESS ACURflENT FORMA HAS BEEN FILED. FORM CM BE COMPLETED FOR INSTALLATIONS. THIS FORI SHOULD BE ACCOMPANIED BY A PLOT PLAN. S FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDE ND STORAGE TANK REGULATIONS FORM 0 (6-95) Fl