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STATE OF CALIFORNIA • STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B "� e 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: / 'wv L z Aq 4!F- I. TANK DESCRIPTION COMPLETE ALL ITEMS— SPECIFY IF UNKNOWN A OWNER'S TANK I.D.X B. MANUFACTURED BY: !I C. DATE INSTALLED(MO/DAYNEAR) e/T 9Z_ D. TANK CAPACITY IN GALLONS: If.TANK CONTENTS IFA-1 IS MARKED,COMPLETE ITEM C. A F-1 2 PETROLEUM CLE FUEL O 90 OILB. B� 1 PRODUCT C 1a REGULAR UNLEADED O 3 DIESEL ❑ 8 AVIATION GAS —\ 1b PREMIUM UNLEADED ❑ 4 GASAHOL ❑ 7 METHANOL ❑ 1c MIDGRADE UNLEADED ❑ 5 JETFUEL ❑ B M85 ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED ❑ 99 OTHER(DESCRIBE IN REM O.BELOW) D. IF(A.1)IS NOT MARKED, ENTER NAME OFSUBSTANCE STORED C.A.S.X: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.B.AND C,AND ALL THAT APPLIES IN BOX D AND A. TYPE OF I❑ I DOUBLE WALL E] 3 SINGLE WALL WITH EXTERIOR UNER ❑ 5 INTERNAL BLADDER SYSTEM E] 95 UNKNOWN SYSTEM SINGLE WALL ❑ 4 SINGLE WALL IN A VAULT ❑ 99 OTHER B. TANK Zq_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°b METHANOL COMPATIBLE WIFRP (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 UNING ❑ 6 UNLINED Ctl__95 UNKNOWN ❑ 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO— D.E)TERIOR ❑ 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 CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) DROPTUBE YES_ NO_ STRIKERPLATE 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 A622 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION A6?1 SINGLE WALL A U 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 U 4 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 ST _EEyL W/COATING A U B 1001/6 METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION ALU/95 UNKNOWN A U 99 OTHER D. LEAK DETECTION ❑ L 1 MECIUUfl UNE LFAK 2 UNE TGMNEM 3 CONTINUOUS UnUMVIAL O 4 EISMRC UNE 5 AUTOMATIC PUMP DETECTOR ❑ MSTNG ❑ MONTORING ❑ LEAK DE1EC10R ❑ SHUTDOWN ❑ 99 OTHER V.TANK LEAK DETECTION �� ❑ 1 VISUAL CHECK p�l 2 MANUAL INVENTORY ❑ 3 LIATIONMONOITZE ORING ❑ 4 GAUL AUTOMATIC ANK ❑ 5 MON ND WATER a ANNUAL TANK ❑ NG TES11 7 MON CONTINUOUS G INTERSTITIAL ❑ B SIR ❑ 9 WEEKLY MANUAL E:]10 MONTHLY TANK ❑ 95 UNKNOWN 99 OTHER TANK GAUGING TESTING VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) 1.ESTIMATED DATE LAST USED(MO/OAYNR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES E:) NO❑ SUBSTANCE REMAINING GALLONS INERT MATERIAL? 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 6 SIGNATURE) LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY# 3115q0 TANK# O� STATE I.D.# F77 1.5 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 (6-95) � SHOULD BE ACCOMPANIED BY A PLOT PLAII,,�FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE U#GROUND STORAGE TANK REGULATIONS PoP00>d6fl7