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. • STATE OF CALIFORNIA _. STATE WATER RESOURCES CONTROL BOARD y r� UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B .. o COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ONSITE ONE REIT ❑ 2 INTERIM PERMIT ❑ { AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ B TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: P.,RCd lac I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A OWNERS TANK I.0.t B. MANUFACTURED BY: P- G DATE INSTALLED(MOCAYNEAR) V 3 1\9 of D. TANK CAPACITY IN GALLONS: I Q V II.TANK CONTENTS IF A-1 IS MARKED.COMPLETE ITEM C. A Z 1 MOTOR VEHICLE FUEL ❑ I OIL B. C. 1• REGULAR UMFAD® ❑ 3 DIESEL ❑ 6 AVIATION GAS ❑ 2 PETROLEUM ❑ 00 EMPTY 2�-1 PRODUCT 1D PRO"VLEADED ❑ { GASAHOL ❑ 7 METHANOL 1C MOf9VDE UMFADED S JET FUEL BS ❑ 8 M ❑ 3 CHEAICALPRODUCT ❑ % UNKNOWN El2 WASTE ❑ 2 LEADED 99 OTHER(DMCRSENREAID.BE.OM D. IF(A.1)IS NOT MARLED. ENTER NAME OF SUBSTANCE STORED C.A S.t 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 ) I DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINEA ❑ 5 NTEPNAL BLADDER SYSTEM ❑ % UN10401YN SYSTEM ❑ 2 SINGLE WALL ❑ a SINGLE WALL IN A VAULT ❑ 99 OTHER B. TANK ❑ 1 BARE STEEL ❑ 2 STAINLESS STEEL ✓5 3 FIBERGLASS ❑ { STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM 8 100% METHANOL COMPATIBLE W/FRP (P—my To ❑ 9 BRONZE - ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER G INTERIOR ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ { PHENOLIC LINING L904GOR ❑ 5 GLASS LINING B UNLINED ❑ % UNKNOWN ❑ 99 OTHER COAflNG IS UNING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO— D.EXTERIOR ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING 3 VINYL WRAP d FIBERGLASS RFJNFORCED PLASTIC CORROSION PROTECTION ❑ 5 CATHODIC PROTECTION E:3 91 NONE �% UNKNOWN ❑ 99 OTHER E SPILL AND OVERFILL,etc. SPILL CONTNNMEMI/ AILED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) DROP TUBE YES_ NO_ STRIKER PLATE YES_✓ NO DISPENSER CONTAINMENT Y� NO IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND,BOTH IF APPLICABLE A SYSTEM TYPE A U 1 SUCTION k L)2 PRESSURE A U 3 GRAVITY A U { FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL U 2 DOUBLE WALL A U 3 LINED TRENCH A U % UNKNOVM A U 99 OTHER C. MATERIAL AND A U 1 SAFE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A U FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL W/COATING A U a 100% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U % UNKNOWN A U 99 OTHER D. LEAK DETECTION i ILauwcu IAB:LFAA z>Fs'n 3 Nrrumut a r> ur: 5urtlaw nAv �� V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 RECONCILIAMANUAL TION V ❑ 3 MONITORING VADOZE ❑ { GAUGING TC TANK ❑ 5 GROUND WATER MONRORING ❑ 6 ANNUATESi1NGTANK 7NUOUS� 9RER^uiR1AL ❑ 9 SUR ❑ 9 TWEEKLY MANANK UAL ❑10 MONTHLY TANK ❑ % UNKNOWN ❑ 99 OTHER GAUGINTESTING VI.TANK CLOSURE INFORMATION PERMANENT CLOSURE IN-PLAcE� 1,ESTIMATED DATE LAST USED(MOIDAY/YR) 2.ESTIMATED QUANTITY OF 3.WAS TANK RI I WITH YES ❑ NO❑ SUBSTANCE REMAINING GALLONS INERT MATERIAL 7 THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST,OF MY KNOWLEDGE, IS TRUE AND CORRECT TANK OWNER'S NAME I _ ATE 1 q (rlwnIDaBaNATwq ,M LOCAL AGENCY USE ONLY THE STATE LD.NUmsiR 6 COMPOSED OFTHE FOUR NUMBERS BELOW COUNTY! JURISDICTION K FACILITY t TANK M STATE I.D.* m PERMIT NUMBER PERMIT APPROVED BY/DATE -- PERMIT EXPIRATION DATE THIS FORM MUST BE ACCOMPANIED BY A PEPYR AAPPPP}}1L�ATION- FORM A.UNLESS A CURRENT FORM A RAS BEEN FILED RM C MUST BE COMPLETED FOR INSTALLATIONS. THIS FORM SHOULD BE ACCOMPANIED BY A PL01W FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING TWDEAGROUND STORAGE TANK REGULATIONS FORM B (6%)