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STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD a UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B 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 REM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED q) DBA OR FACILITY NAME WHERE TANK IS INSTALLED: J I. TANK DESCRIPTION COMPLETE ALL ITEMS– SPECIFY IF UNKNOWN A OWNER'S TANK I.D.# B. MANUFACTURED BY: UNkOWrI 71 C.,DATE INSTALLED(MO/DAYNEAR) Unknown D. TANK CAPACITY IN GALLONS: 550 II.TANK CONTENTS IF A-1 IS MARKED,COMPLETE ITEM C. A, I MOTOR VEHICLE FUEL ❑ 4 OIL B. C ❑ la REGULAR UNLEADED ® 3 DIESEL ❑ 6 AVIATION GAS 2 PETROLEUM 80 EMPTY ® i PRODUCT ❑ lb PREMIUM UNLEADED ❑ 4 GASAHOL ❑ 7 METHANOL ❑ le 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(AA)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 A. TYPE OF ❑ 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR UNER ❑ 5 INTERNAL BLADDER SYSTEM ❑ 95 UNKNOWN SYSTEM ® 2 SINGLE WALL ❑ 4 SINGLE WALL IN A VAULT ,❑ 99 OTHER B. TANK ® 1 BARE STEEL O 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 W/FRP (Primary Te9k) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER C.INTERIOR ❑ 1 RUBBER LINED F-1 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING LINING OR ❑ 5 GLASS UNING M 6 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH IDD% METHANOL? YES_ NO— D.EXTERIOR ❑ 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,8[C. SPILL CONTAINMENT INSTALLED(YAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) DROPTUSE YES NO STRIKERPLATE YES_ NO DISPENSER CONTAINMENT YES_ NO-�'_ IV.PIPING INFORMATION CIRCLE A IFABOVEGROUNDOR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A 4V1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION A 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 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 STEEL W/COATING A U B 100% 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 l MEC7 M ME LEAK 2 ME POWNESS 3 CMINWUS iNTERSMAL 4 ELEMMIC UNE 5 AUMMAM Rues ❑ OEfECiOfl ❑ TESTING MOMTORING 1FAN DETECTOR E] SHUTDOWN ❑ 99 OTHE V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK D 2 RECONCILIATIONANUAL ORV ❑ 3 MONIITORING E] 4 GAUGING AUTOMATIC TANK ❑5 MONITORING GROUND TER ❑ 8 TESTINGTANK ❑ 7 MON INUOU INTERSTITIAL ❑ 8 SIR E:] 9 WEEKLY MANUAL E]10 T1 STHLY TANK 95 UNKNOWN ❑99 OTHER NG VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) 1.ESTIMATED DATE LAST USED(MO/DAYNR) 2.ESTIMATED QUANTITY OF 225 3.WAS TANK FILLED WITH YES NO ISI Unknown SUBSTANCE REMAINING J GALLONS NERT MATERIAL? ❑ I_I THIS FORM HAS BEEN CO LET,ED U DER ENALTY F PER RY D T T KiYQWLEDGE, IS TRUE AND CORRECT TANK OWNER'S NAME VIVI DATE (PRINTED 491GNATUfl 3/9/!18 LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OFIE FOUR NUMBERS BELOW 77 COUNTY# JURISDICTION# FACILITY# n TANK# STATE I.D.# m = i i i i TT71 i ii o -5/re746- PERMIT NUMBER PERMIT APPROVED BV/DATE PERMIT EXPIRATION DATE THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICAJION-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. FORM C MUST BE COMPLETED FOR INSTALLATIONS. THIS FORM SHOULD BE ACCOMPANIED BY A PLOT PJWLE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THEORGROUND STORAGE TANK REGULATIONS FORM B (6-95)