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9 0 STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD Jd� tl'o UNDERGROUND STORAGE TANK PERMIT APPLICATION -FORM B 1 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 REM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ® 8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: SINCU-%EW I" SrjkTjbfA 43.Qb ES LGMTMJ IC Lp D I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A OWNER'S TANK I.D.# AL B. MANUFACTURED BY: L4 k bui tj C. DATE INSTALLED(MOIDAYIYEAR) VA VA 1C D. TANK CAPACITY IN GALLONS: I C) V IL TANK CONTENTS IF A-1 IS MARKED,COMPLETE ITEM C. A O 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C. ® 1a REGULAR UNLEADED ❑ 3 DIESEL ❑ 6 AVIATION GAS ❑ 2 PETROLEUM ❑ 80 EMPTY ❑ 1 PRODUCT ❑ ib PREMIUM UNLEADED ❑ 4 GASAHOL ❑ 7 METHANOL ❑ 1c MIDGRADE UNLEADED ❑ 5 JET FUEL ❑ 8 M85 ❑ 3 CHEMICALPRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED ❑ 99 OTHER(DESCRIBE IN REMO.BELOM D. IF(A.1)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 A. TYPE OF ❑ 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 5 INTERNAL BLADDER SYSTEM © 95 UNKNOWN SYSTEM ❑ 2 SINGLE WALL ❑ 4 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 WIFRP (Primary Tok) ❑ 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 ® 95 UNKNOWN ❑ 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 10D% METHANOL? YES_ NO— D.EXTERIOR ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC CORROSION 95 UNKNOWN ❑ 99 OTHER PROTECTION ❑ 5 CATHODIC PROTECTION F] 91 NONE SPILLCONTAINMENTINSTALLED(YEAR)AUwrNY4N OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) E.SPILL AND OVERFILL,9L0. DROPTUBE YES_ NO STRIKER PLATE YES_ NO_ DISPENSER CONTAINMENT VES NO_ IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION A 8 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 4 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U7 STEEL W/COATING A U B 100% METHANOL COMPATIBLE WIFRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION p U 95 UNKNOWN A U 99 OTHER 1 ARCNANGL Lxff LEAN 2 NNE TNJOWIS 3 GONUNUWS WfEASTIML ❑4 RSCUAE ❑5 AIROMATC PIIW ®99 OTHER UAAMIAD 1) D. LEAK DETECTION ❑ �Dg ❑ TESiNO ❑ MGNrawxG LEAK=moR sxuroovm V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 MANUAL RECONCILIATIONINVENTORY ❑ 3 MONITORING ❑ 4 GAUGING AUTOMATIC TANK ❑5 MON TORINGGROUND TER ❑ 6 TTEESTINGNUAL TANK ❑ 7 MON TOR NG INTERSTITIAL ❑ 8 SIR ❑ 9 WEETANKLY MANUAL ❑10 MONTHLYTESTING TANK � 95 UNKNOWN ❑99 OTHER VL TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PUCE) 1.ESTIMATED DATE LAST USED rAY/YR) 2 SUBSTANCE UANTIITY OF GALLONS 3 WAINERT MATERIAL 7H YES ]K NO❑ APao 1 THIS FORM HAS BEEN COMPLETED UNDER P L OF RJURY TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT TANK OWNER'S NAM -�A� DATE (PRINTED 6 SIGNATURE) i F L 1P�C IS 2 �I LOCAL AGENCY USE ONLY THE STATE L15.NUMBF,AVIS COMPOSED OF THE FOUR NUMBERS BELOW _C�Co&Ty# JURISDICTION# FACILITY# TANK It STATE I.D.# m = FTL= PERMIT NUMBER PERMIT APPROVED BYIDATE PERMIT EXPIRATION DATE 71 THIS FORM MUST BE ACCOMPANIED BY A PERMIT AP�TION-FORM A,UNLESS A CURRENT FORMA HAS BEEN FILE�M C MUST BE COMPLETED FOR INSTALLATIONS. THIS FORM SHOULD BE ACCOMPANIED BY A PLOIW. FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING DERGROUND STORAGE TANK REGULATIONS FORM 8 (6-95)