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S i ATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION -FORM B COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY I NEW PERMIT r7 3 RENEWAL PERMIT - 5 CHANGE OF INFORMATION 7 PERMANENTLY C'.A ON SITE ONE ITEM INTERIM PERMIT a AMENDED PERMIT 6 TEMPORARY TANK CLOSURE 8 T REk VED Z OBA OR FACILITY NAME WHERE TANK IS INSTALLED: l^/�( ;;;iari i I7 i I. TANK DESCRIPTION COMPLETE ALLIrMs- saECIFYIFwauowN } A OWNER'S TANK I.0.a I-�-,^- 1 -.�� I B. MANUFACTURED 3Y: C. DATE INSTALLED(MOfOAY/YEAR) 0. TANK CAPACITY :N GALLONS: II.TANK CONTENTS IF A-1 IS MARKED.COMPLETE ITEM C. A IJ t MOTOR VEHICLE FUEL s OIL 8. C. is REGULAR UNLEADED 3 DIESEL �L-j! 6 AVIATION GAS ::PREMIUM UNLEADED 4 GASAHOL I I T METHANOL 2 PETROLEUM C 80 EMPTY ® 1 PRODUCT Ic MOGRADE UNLEADED 5 JET FUEL En B M85 3 CHEMICALPRODUC 95 UNKNOWN 2 WASTE '� 2 LEADED F, 99 OTHER(OE'PCRMEW ITEM D.BELOW) 0. IF(A t)IS NOT MARKED. ENTER NAME OF SUBSTANCE STORED C.A S.D: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A S.AND C.ANO ALL THAT APPUES IN BOX O AND E A. TYPE OF 1 DOUBLE WAIL 3 SINGLE'NALL WITH EXTERIOR LINER 5 INTERNAL BLADDER SYSTEM = 95 UNIQJOWN SYSTEM Q 2 SINGLE WALL ❑ A SINGLE WALL IN A VAULT 99 OTHER B. TANK I BARE STEEL 2 STAINLESS STEEL 3 FIBERGLASS a STEEL CLAD W/FLSERGUASS REINFORCED PLASTIC MATERIAL Q 5 CONCRETE 8 PCLY. NYL CHLORIDE J 7 ALUMINUM 8 ICO% METHANOL COMPATIBLE W/FRP (Primary Teak) l�J 9 BRI 10 GALVANIZED STEEL ❑ 95 UNKNOWN G 99 OTHER C.INTERIOR L.J I RUBBER LINED 2 AU(YO LINING 3 EPDXY LINING 4 PHENOLIC LINING LINING OR 5 GLASS LINING 6 UNLINED 95 UNKNOWN 99 OTHER COATING IS UNING MATERIAL COMPATIBLE WITH 10C% METHANOL7 YES_ NO— D.EXTERIOR 1 POLYETHYLENE WRAP 2 COATING 3 VINYL WRAP F7- 4 FIBERGLASS REINFORCED PLASTIC CORROSION ^^�� PROTECTION U 5 CATHODIC PROTECTION '�� 91 NONE 95 UNKNOWN L 99 OTHER E.SPILL AND OVERFILL,etc. SKILL CONTAINMENT INSTALLED(YEAR) OVERHU,REVENTICN EQUIPMENT INSTALLED(YEAR) ; DROP TUBE Y OC NO_ STRIKER PLATE YES (_l NO OISPENSER 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 A 2 PRESSURE A U 3 GRAVITY A U 4 FLEX18LEPIPING A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND A U 1 BARE STEEP A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A U 4 FIBERGLASS PIPE CORROSION A U 3 ALUMINUM A U 5 CONCRETE A U 7 STEEL W/COATING A U 3 100% METHANOL CCMPATIBLE W/F_RU.P, PROTECTION A U 9 GALVANIZED STEEL/A U f0 CATHODIC PROTECTION A U 95 UNKNOWN A®99 OTHER r-d:IIOG 1^L�Y�metOII D. LEAK DETECTION ®1 uFowMnt uIF IFAK r,2 r TlalpxEAs 3 mxlnA+aO mTnsrmAL ]4 Brs�Roxc w �5.=W=Aur n 99 OTHER ODFcwA re VaNrawc 1AK oeT[caa 9ArtmwK V.TANK LEAK DETECTION I� 1 VISUAL CHECK 2 M CONCILIATIONONE ❑ 3 MONITORING 4 AUTO NG C TANK 5 GROUND MONITORINGS J P ANNUAL TEG NGTArvK 7 N INUOU INTERSTITIAL = 8 SIR ❑ 9 WEE AY MANUAL INC a 10 MONTHLY TANK 95 UNKNOWN 99 OTHER MO VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) 1.ESTIMATED DATE LAST USED(MONAYAT) 2.ESTIMATED QUANTITY OFI 3. AS TANK FILLED` ITH ,E a NO SUBSTANCE REMAINING GALLONS INEATMATERIAL? THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO TrIE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT TANK OWNER'S NAME yIt-((,�1CTI IA0 _ r DATE �A./ ,A PRRRm6LGNATIREI f _ IL>7`\ 1 ) 1 �-1 1 ^ v, ' LOCAL AGENCY USE ONLY THE STATE I.D.NUMISER IS COMPOSED OF THE FOUR NUMBERS BELOW i r COUNTY a JURISDICTION a FACILITY s GO47S/79 TANK M J L - STATE I.D:n 1 2-131 /12-13 13 C 7 q 911 4- l PERMIT NUMBER I PERMIT APPROVED SYMATE PERMIT EXPIRATION DATE THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPD`,'UN-FORM A.UNLESS A CURRENT FORM A HAS BEEN FILED. F,..OD MUST BE COMPLETED FOR INSTALLATIONS.THIS FORM SHOULD BE ACCOMPANIED BY A PLOT PI TLE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE. TGROUND STORAGE TANK REGULATIONS FORM 8 I6-95)