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STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B i COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY F-� i NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ON ONE REM ❑ 2 INTERIM PERMIT F—] 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE 8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: 113 , I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A. OWNER'S TANK I.D.It 36rn I S. MANUFACTURED BY: C. DATE INSTALLED(MO(DAY/YEAR) � D. TANK CAPACITY IN GALLONS: QDc. II.TANK CONTENTS IF A-1 IS MARKED,COMPLETE ITEM C. A. &f 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C. ❑ 1a REGULAR UNLEADEDDIESEL ❑ 8 AVIATION GAS In 2 PETROLEUM ❑ 80 EMPTY 1 PRODUCT ❑ 1b PREMIUM UNLEADED ❑ 4 GASAHOL ❑ 7 METHANOL ❑ iC MIDGRADE UNLEADED ❑ 5 JET FUEL 8 M85 ❑ 3 CHEMICALPRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED ❑ 99 OTHER(DE IBE W REM D.BELOM D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S.#: III. TANK CONSTRUCTIOV MARK ONE ITEM ONLY IN BOXES A,0,AND C,AND ALLTHATAPPLIES IN BOX D AND E A. TYPE OF ❑ 1 DOUBL WALL E:] 3 SINGLE WALL WITH EXTERIOR LINER ❑ 5 INTERNAL 0 R SYSTEM ❑ 95 UNKNOWN SYSTEM 2 SINGLE ALL ❑ 4 SINGLE WALL IN A VAULT ❑ 99 OTHER B. TANK 1 BARE STE ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL C D W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% ETHANOL COMPATIBLE W/FflP (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 ER C.INTERIOR ❑ 1 RUBBER UNED ❑ 2 ALKYD LINING ❑ 3 EPDXY UNING ❑ PHENOLIC LINING LINING OR ❑ 5 GLASS LINING ❑ 8 UNLINED ❑ 95 UNKNOWN 99 OTHER COATING IS UNING MATERIAL COMPATIBL WITH 10D% METHANOL? YES— NO— D•EXTERIOR ❑ 1 POLYETHYLENE WRAP 2 COATING ❑ 3 VINYL WR ❑ d FIBERGLASS REINFORCED PLASTIC CORROSION PROTECTION ❑ 5 CATHODIC PROTECTON ❑ i NONE ❑ 95 UNKNO N ❑ 99 OTHER E.SPILL AND OVERFILL,BSC. SPILL CONTAINMENT INSTALLE EAR) OVEflFILL EVENTION EQUIPMENT INSTALLED(YEAR) DROP TUBE VES_ NO STRIKER PLATE VES NO_ DISPENSER CONTAINMENT VES_ NO IV.PIPING INFORMATION CIRCLE A IF ABOVE ORO OR U IF UNDERGROU ,BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION A U 2 PRE URE 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL A U 2 DOUG WALL A U 3 UNED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND A U 1 BARE STEEL A U 2 STAINLESS L A U 3 POLYVINYL CHLORIDE(PVC)A U 4 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL W/COATING A U 8 1001/6 METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHO PR CTION A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION 01 MECNANCAL UNE IFAK 2 LINE TIGMNESS jn 3 COMINU S IMERSTOIAL ❑4 SAMOI11C LINE 5 AIROMATIC PUMP O 99 OTHER OEIECIOR TESTING MONTgiI LEAN DETECTOR S4UTOOWN V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 RECONCIUATIANUAL N RY ❑ 3 MONOITORING ❑ 4 GAUGING AUTOMATIC TANK ❑ 5 MONITORING GROUNDWATER ❑ 8 7ESTINGNUAL TANK ❑ 7 MONITORING INTERSTITIAL ❑ 8 SIR ❑ 9 TANKLY MANG ❑10 MOTESNTHLY TANK ❑ 95 UNKNOWN ❑ 99 OTHER NG VI.TANK CLOSURE INFORMATION(PERMAN T CLOSURE IN-PLACE) 1.ESTIMATED DATE LAST USED(MO/DAY/YR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH VES ❑ 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 A SIGNANRE3 LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW .2 COUNTY# JURISDICTION# FACILITY# TANK# STATE 04 I I mI 1ED 1 / 160,1711,0[7 PERMIT NUMBER PERMIT APPROVED BYIDATE PERMIT EXPIRATION DATE (,n) 71 THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICA77��ON-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. FORUST BE COMPLETED FOR INSTALLATIONS. THIS FORM SHOULD BE ACCOMPANIED BY A PLOT PL' ETHIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE U ROUND STORAGE TANK REGULATIONS FORMS (6.95)