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�cC9 CO STATE OF CALIFORNIA +�4� '. . STATE WATER RESOURCES CONTROL BOARD :m�I UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B ;s - 1 COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ON SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: �Z y `7 / '� T7> S',-. L c;�o I. TANK DESCRIPTION COMPLETE ALL ITEMS— SPECIFY IF UNKNOWN A OWNER'S TANK 1.0.# I B. MANUFACTURED BY: C. DATE INSTALLED(MC/DAWYEAR) D. TANK CAPACITY IN GALLONS: j UU IL TANK CONTENTS IFA-11SMARKED.COMPLETE ITEM C. 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C. ❑ 1a REGULAR UNLEADED 3 DIESEL ❑ 6 AVIATION GAS A. PETROLEUM ❑ 80 EMPTY 1 PRODUCT ❑ 1b PREMIUM UNLEADED ❑ 4 GASAHOL ❑ 7 METHANOL ❑ 1c MIDGRADE UNLEADED ❑ 5 JETFUEL ❑ 8 M85 ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED ❑ 99 OTHER(DESCRIBE IN REM 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 E A. TYPE OF IIL�L�,\ 1 DOUBLE WALL 3 SINGLE WALL WITH EXTERIOR LINER ❑ 5 INTERNAL BLADDER SYSTEM ❑ 95 UNKNOWN SYSTEM LJ'2 SINGLE WALL ❑ 4 SINGLE WALL IN A VAULT ❑ 99 OTHER B. TANK / BARE STEEL 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 9S UNKNOWN ❑ 99 OTHER C.INTERIOR ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING LINING OR ❑ 5 GLASS LINING ❑ 6 UNLINED 95 UNKNOWN ❑ 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO— D.EXTERIOR ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC CORROSIONg7 NONE X1UNKNOWN 99 OTHER 95 UNKO PROTECTION ❑ 5 CATHODIC PROTECTION ❑ ®. ❑ E.SPILL AND OVERFILL,BIC. SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) DROPTUBE YES_ NO_ STRIKERPLATE YES_ NO_ DISPENSER CONTAINMENT YES_ NO IV. PIPING INFORMATION CIRCLE A IFABOVEGROUNDOR U IF UNDERGROUND,BOTH IF APPUCABLE 0A,(D ,C A. SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLEPIPING A U 99 OTHER B. CONSTRUCTION A U 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 U 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 8 100% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER i WCNANIM NNE LEAK 2 UNE TGWKSa 3 CONTN9Wa WERSTRML 4 ELE=11 LINE 5 AIROMATIC PUAP gg OTHER D. LEAK DETECTION ❑ MTOVOR ❑ TESrNG ❑ uoMT.'IX ❑ LEAK oETEcroR ❑ SHIJ 9 M ❑ V.TANK LEAK DETECTION ❑ 14 1 VISUAL CHECK ❑ 2 pECONCILNATIONORY ❑ 3 MONITORING ❑ 4 AUTOMATGAUGINGIC TANK ❑ 5 GRKMONITORINGTER ❑ 6 TESTIAL NGTANK ❑ 7 MON TORNG INTERSTITIAL ❑ B SIR ❑ 9 WANKGAUGANGAL ❑10 MONTHLY TANK ❑ 95 UNKNOWN ❑99 OTHER NG VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-Puce) 7.ESTIMATED DATE LAST}ISED(MOIDAV/YR) 2.ESTIMATED OUANTTY OF 9� 3.WAS TANK FILLED WITH YES ❑ NO ❑ /� SUBSTANCE REMAINING l•/ GALLONS INERT MATERIAL? THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT TANK OWNER'S NAME DATE (PRINTED 6 SIGNAWREI LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY# TANK# STATE I.Dl p 1 � Kp IG - /i PERMIT NUMBER PERMIT APPROVED BYIDATE PERMIT EXPIRATION DATE THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. FOR BE COMPLETED FOR INSTALLATIONS.THIS FORM SHOULD BE ACCOMPANIED BY A PLOT PLOLE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING 7HE GROUND STORAGE TANK REGULATIONS FORM 8 (6.95)