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STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD coo UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B "� m COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. 1 MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ ] PERMANENTLY CLOS ONSITE ONE REM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: 41A W —c—U,44, G I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A OWNER'S TANK I.D.N D .L O Z B. MANUFACTURED BY: C. DATE INSTALLED(MOIDAYNEAR) /d /�'AC' �F- / D. TANK CAPACITY IN GALLONS: OO II,TANK CONTENTS IFA-1 IS MARKED,COMPLETE ITEM C. q, MOTOR VEHICLE FUEL E] / OIL B. C ❑ 1a REGULAR UNLEADED ❑ 3 DIESEL ❑ 8 AVIATION GAS `�❑//`""' 2 PETROLEUM E:] 80 EMPTY V 1 PRODUCT L,ec MIRDGIRADE UNLEADED ❑ 5 ET FUEL ❑ 8 M85 ANOL ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN / '❑ lb— 2 WASTE ❑ 2 LEADED ❑ 99 OTHER(DESCRIBE IN REM D.BELOVO 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 E 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 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑—' 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLEWIFRP (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 ❑ 8 UNLINED 95 UNKNOWN E::] 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 10D% METHANOL? VES NO_ D.EXTERIOR ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC CORROSION PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE ❑95 UNKNOWN ❑ 99 OTHER E.SPILL AND OVERFILL,BIC. SPILL CONTAINME T STALLED(YEAR) Q OVERFILL VIEVENTION EQUIPMENT INSTALLED(YEAR) DROPTUBE 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 W2 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL A 2- 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)A 4 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U ] STEEL W/COATING A U 8 100% METHANOL COMPATIBLE WIFRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION [:]l MECHMNCAL UNE LEAK ❑2 UNE TIGHTNESS ❑3 GWINUMS INTERSTm,LL 4 ELEMM MC LINE 5 AIROIMTC PUMP OETECfOR TESTING MOMTMING ❑ LEAN OEiEC10R ❑ SHUTWWN ❑ 99 OTHER V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 MANUAL UATIONORY ❑ 3 VADOZE ❑ 4 AUTOGAUMATIC TANK ❑ 5 MONITORINGGROUND WATER ❑ 6 ANNUALTANK CONTINUOUS MONITORING INTERSTITIAL ❑ 8 SIR ❑ 9 WTESTING EEKLY MANUAL ❑10 MONTHLY TANK ❑ 95 UNKNOWN ❑ 99 OTHER TANK GAUGING TESTING V(TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) 1.ESTIMATED DATE LAST USED(MOA]AYIYR) 2.ES11MATED QUANTITY OF 3.WAS TANK FILLED WITH SUBSTANCE REMAINING GALLONS INERT MATERIAL 7 YES ❑ NO❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT TANK OWNER'S NAME DATE (PRINTED 8 SIGNATURE) LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY# 00377 TANK# I I STATE I.Dl m a 3 ® 5 D 8 5101 PERMIT NUMBER PERMIT APPROVED BYIDATE PERMIT EXPIRATION DATE THIS FORM MUST BE ACCOMPANIED BY A PERMITAPPLI� ON-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. F C MUST BE COMPLETED FOR INSTALLATIONS.THIS FORM SHOULD BE ACCOMPANIED BY A PLOT�FlLE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THIIWRGROUND STORAGE TANK REGULATIONS FORM B (6-95) I/ro /qg f A ,