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�►. - 0 STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD r� 4 UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY 1 NEW PERMIT ❑ 3 RENEWAL PERMIT .2�j 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ON SITE ONE REM ❑ 2 INTERIM PERMIT ❑ A AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ e TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS OWALLTD: P,ti �AC (9 Oj Ojs ST Le�—�D N I. TANK DESCRIPTION COMPLETE ALL ITEMS— SPECIFY IF UNKNOWN A OWNERS TANK I.D.# B. MANUFACTURED BY: kRl S C. DATE INSTALLED(MCYDAYAFM) I D. TANK CAPACITY IN GALLONS: 12 O U IL TANK CONTENTS IF M1 IS MARKED,COMPLETE REM C. M1 MOTOR VENICLE FUEL ❑ 4 OIL S. C. to RE I M UNEADED 3 DIESEL E 6 AVIATK)N GAS ❑ 2 PETROLEUM ❑ 9D EMPTY E_1 PRODUCT 1D HEWN UNLEADED a GASAHOL Q 7 METHANOL 1c MDOIMDE UNFIDTD 5 JETFUEL ❑ e M65 E] 9 CHEMIGLPROWCT ❑ 95 UNIOJONRJ 2 WASTE 2 LEADED 99 OMER MUCASE N ITEM D.SEDM D. IF(A1)IS NOT MARKED. ENTER NAME OF SUBSTANCE STORED C.A S 9: III. TANK CONSTRUCTION MARK ONE REM ONLY IN BOXES A.B,AND C,AND ALL THAT APPLIES IN BOX D AND E A. TYPE OF �4 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 5 INTERNAL BLADDER SYSTEM ❑ 95 UNKNOWN SYSTEM ❑ 2 SINGLE WALL ❑ a SINGLE WALL IN A VAULT ❑ 99 OTHER B. TANK ❑ 1 BARE STEEL. ❑ 2 STAINLESS STEEL �3 FIBERGLASS ❑ I STEEL CLAD w FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ B 100% METHANOL COMPATIBLE WIFRP WT'MY TSV ❑ 9 BROIL ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER G INTERIOR ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOUC UNIG LBBNG OR ❑ 5 GLASS L9#G 6 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 10D%METHANOL? YES— NO— D.EXTERIOR ❑ 1 POLYEnWLEE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP s FIBERGLASS REINFORCED PLASTIC CORROSION PROTEC.TM ❑ 5 CATHODIC PROTECTION �N$❑7 91 NONE ❑95 UNKNOWN ❑ 99 OTHER E SPILL AND OVEAFRL,etc �LL�TNHMEM\/ ALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) 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 2 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION A U i SINGLE WALL ACUj 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER G MATERIAL AND A U 1 BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLDWDE(PVC)A CU 14 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL WICRATING A U B l00% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION ®1 �IRaL IJN IFAX ❑2 i TToma<unartNu 3 wxnAws xlEasnnu ❑AEa u¢ s ruP O w oTM� V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 MANUAL RECONCILIATION ❑ 3 VADOZEMONITORING ❑ A GAUGING TANK ❑5 GROUND MONITORING ❑6 ANNUAL TESTING 7 AI�D�SG WTERb�AL ❑ 9 SIR ❑ 9 TANK GAUGING MANUAL ❑10 MONTHLY TANK ❑ 95 UNKNOWN ❑99 OTHER VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE INrLACE) 1.ESTIMATED DATE LAST USED(MO'DAYfM 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED 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 OWNERS NAME ! \ DATE O MFINTM&A INATUW ( LOCAL AGENCY USE ONLY THE STATE LD.NUME14 IS COMPOSED OF THE FOUR NUMBERS 8 DW COUNTY# JURISDICTION# FACIUTY TANK# STATE ILD:# m PERMIT NUMBER. PERMIT APPROVED BYIDATE PERMIT EXPIRATION DATE THIS FORM MUST BE ACCOMPANIED BY A POW TION-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILEIdWIY C MUST BE COMPLETED FOR INSTALLATIONS. THIS FORM SHOULD BE ACCOMPANIED BY A PLN RLE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTNCi_NDERGROUND STORAGE TANK REGULATIONS FORM B (695)