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0 • •yaw..,'cot; STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B , o 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 ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ® 8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: U- WA k- VEM&w d4. l.OD I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A OWNER'S TANK I.D.i B. MANUFACTURED BY: Q Ai C. DATE INSTALLED(MOIDAY/VEAR) YN D. TANK CAPACITY IN GALLONS: II.TANK CONTENTS IF A-1 IS MARKED,COMPLETE ITEM C. ❑ 1a REGULAR UNLEADED ❑ 3 DIESEL ❑ 8 AVIATION GAS A ® 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. O ® lb PREMIUM UNLEADED O 4 GASAHOL O 7 METHANOL ❑ 2 PETROLEUM ❑ 80 EMPTY ❑ I PRODUCT ❑ Ic MIDGRADE UNLEADED 5 JET FUEL B M85 ❑ 3 CHEMICALPRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED ❑ 99 OTHER(DESCRIBE IN ITEM D.BELOW) 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.EL AND C.AND ALL THAT APPLIES IN BOX D AND F-1I DOUBLE WALL F-13 SINGLE WALL WITH EXTERIOR LINER E:] ®5 INTERNAL BLADDER SYSTEM 95 UNKNOWN A. TYPE OF SYSTEM F72 SINGLE WALL ❑ 4 SINGLE WALL IN A VAULT ❑ 99 OTHER ❑ 1 BARE STEEL 712 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B. TANK MATERIAL ❑ 5 CONCRETE ❑ 8 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ® 95 UNKNOWN ❑ 99 OTHER C.INTERIOR ❑ I RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC UNING LINING OR ❑ 5 GLASS LINING ❑ B UNUNED ® 95 UNKNOWN ❑ 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? VES_ NO— D.EXTERIOR ❑ I POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC CORROSION g1 NONE ©95 UNKNOWN ❑ 99 OTHER PROTECTION ❑ 5 CATHODIC PROTECTION ❑ SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INS TALLED(YEAR)�NY,NOtiN E.SPILL AND OVERFILL,CTC. 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 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 U 2 DOUBLE WALL A U 3 LINED TRENCH A e 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 a CONCRETE A U 7 STEEL W/COATING A U B 100% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A() 95 UNKNOWN A U 99 OTHER I MECNN K&UNE LEAK 2 UNE TX.NmE55 ❑3 LLNIINUW3 INTEARiIILLL ❑4 EU:;mwc UNE ❑5 AlUWPL PUMP ® 99 OIHER% { �y D. LEAK DETECTION ❑ maw ❑ TESRNG EN1NTM TN(DETECTOR NIUI00WN V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 RECO CIUATONORY ❑ 3 MONIITORING ❑ 4 AUTOGAUGING C TANK ❑S GROUNDWAMONITORING TESTING ❑B TAENNUAL STINGTANK ❑ 7 CONTINUOUS MONITORING INTERSTITIAL ❑ 8 SIR ❑ 9 TANK GAUGING ❑10 M STTIING LY TANK © g5 UNKNOWN ❑99 OTHER VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) 1.ESTIMATED DATE LAST USED(MO/DAV/YR) 2.ESTIMATED QUANTITY OF /+� 3.WAS TANK FILLED WITH YES ® NO❑ SUBSTANCE REMAINING � GALLONS INERT MATERIAL 7 THIS FORM HAS BEEN COMPLETED UNDER PENAL PER ,A E BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT TANK OWNER'S NAM ��`��E'�'' "I, DATE �J (PRINTED A SIGNATURE) tyu fS LOCAL AGENCY USE ONLY THE STATE I.D.NU BER IS OSED OF THE FOUR NUMBERS BELOW COUNTY M JUR ICl10N i FACIFFT1= T= STATE ILD:# m PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE THIS FORM MUST BE ACCOMPANIED BY A PERMIT ARJWTION-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILE RM C MUST BE COMPLETED FOR INSTALLATIONS. THIP SHOULD BE ACCOMPANIED BY A PL N. FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTINGqFNDERGROUNO STORAGE TANK REGULATIONS FORME (6-95)