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• STATE OF CALIFORNIA • e Awe •ren STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B I COMPLETE A SEPARATE FORM FOR EAC TANK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLO SITE ONE REM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOV DBA OR FACILITY NAME WHERE TANK IS INSTALLED: IZ2117 I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A OWNER'S TANK I.D.# yt - {57 B. MANUFACTURED BY: &Z Am C. DATE INSTALLED(MO/DAY/YEAR) If D. TANK CAPACITY IN GALLONS: II.TANK CONTENTS IF A-1 IS MARKED,COMPLETE ITEM C. G 1a PEGUUR UNLEADED ❑ 3 DIESEL ❑ 8 AVIATION GAS A 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. ❑ lb PREMIUM UNLEADED ❑ 4 GASAHOL ❑ 7 METHANOL F__] 2 PETROLEUM ❑ 80 EMPTY PRODUCT ❑ 1C MIDGRADE UNLEADED ❑ 5 JET FUEL ❑ 8 M85 ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED ❑ 99 OTHER(DESCRIBE IN ITEM D.BELOW) D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S.#: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.B,AND C.AND ALL THAT APPLIES IN BOX D AND F] IXC USLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 5 INTERNAL BLADDER SYSTEM ❑ 95 UNKNOWN A. TYPE OF � 99 OTHER L�/ SYSTEM 2 SINGLE WALL ❑ 4 SINGLE WALL IN A VAULT ❑ B. TANK 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ B 100% METHANOL COMPATIBLE W/FRP (Primary Twk) ❑ 9 BRONZE I❑ 110///GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER C.INTERIOR ❑ 1 RUBBER LINED LKYD LINING ❑ 3 EPDXY UNING ❑ 4 PHENOLIC LINING LINING OR F-15 GLASS LINING od 6 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER COATING IS UNING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO— D.EXTERIOR ❑ 1 POLYETHYLENE WRAP ❑ OATING El VINYL WRAP E] 4 FIBERGLASS REINFORCED PLASTIC CORROSION ❑ 99 OTHER PROTECTION E:] 5 CATHODIC PROTECTION 91 NONE 95 UNKNOWN ❑ SPILLCONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) E.SPILL AND OVERFILL,BTC. 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 AID 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER B, CONSTRUCTION A 9 1 SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND 1 BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A U 4 FIBERGLASS PIPE CORROSION A 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL W/COATING A U 8 100% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION AU 95 UNKNOWN A U 99 OTHER ❑ C 1 MEOUMCAL ONE UI 2 UNE TIGN94:55 3 MNUWS aNERSTTIIAL 4 EUMMIC LINE E:]5 AUfOENTIC RUMP ❑ 99 OTHER D. LEAK DETECTION ❑ GEIECTOR ❑ TEd w MOMTOMND LEV(DEIECroR S411f6GWN V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK le 2 MANUAL INVENTORY ❑ 3 MONOITORING ❑ 4 GAUGING NG AUTOMATIC TANK ❑5 MONITORING POUND TER 6 TESTINGN A TANK RECONCILIATION ❑ 7 MON TORWG INTERSTITIAL ❑ 8 SIR ❑ 9 7pNK GAUGINGAL ❑10 MONTHLTESTING TANK ❑ 95 UNKNOWN ❑99 OTHER VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PUCE) 1.ESTIMATED DATE LAST USED(MOIDAYNR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES ❑ NO ❑ SUBSTANCE REMAINING GALLONS INERTMATERIAL? THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT DATE TANK OWNER'S NAME (PRINTEDa91GNATURET LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION If �FA�CILITY# TANK# STATE 04 � 2 I / 5 1 if PERMIT NUMBER PERMIT APPROVED BYA)ATE PERMIT EXPIRATION DATE 5191"1 THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A.UNLESS A CURRENT FORM A HAS BEEN FILED. FO C MUST BE COMPLETED FOR INS LLATI NS. IS FORM SHOULD BE ACCOMPANIED BY A PLOT PLWILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING FO STORAGE TANK REGULATIONS FORa034"T FORME (6.95)