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STATE OF CALIFORNIA �� ac*� STATE WATER RESOURCES CONTROL BOARD +Y'd� d e UNDERGROUND STORAGE TANK PERMIT APPLICATION-FORM B > - , COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY I 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 ❑ 6 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: ! ! ce. �—� I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A OWNER'S TANK I.D.# 3 B. MANUFACTURED BY: C. DATE INSTALLED(MOMAYA'EAR) V—3— 8 D. TANK CAPACITY IN GALLONS: a- O II.TANK CONTENTS IF A-1 IS MARKED,COMPLETE ITEM C. A ❑ 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C. 0 1a REGULAR UNLEADED 3 DIESEL ❑ 6 AVIATION GAS 2 80 EMPTY PRODUCT E] lb PREMIUM UNLEADED 4 GASAHOL ❑ 7 METHANOL PETROLEUM ❑ ❑ ❑ 1c MDGRADE UNLEADED ❑ 5 JET FUEL ❑ 8 M85 ❑ 3 CHEMICALPRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED ❑ 99 OTHER(DESCRIBE IN ITEMD.BELom 0. IF(A.1)IS NOT MARKED, ENTER NAME OFSUBSTANCE STORED C.AS#: 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 LINER ❑ 5 INTERNAL BLADDER SYSTEM ❑ 95 UNKNOWN SYSTEM ❑ 2 SINGLE WALL ❑ 4 SINGLE WALL IN A VAULT ❑ 99 OTHER B. TANK ❑ I BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS 02-14�STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ a POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 1001/6 METHANOL COMPATIBLE W/FRP (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER C.INTERIOR ❑ 1 RUBBER LINED ❑^/2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING LINING OR ❑ 5 GLASS LINING D2 ° UNLINED ❑ 9!5,UNOWN ❑ 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO— D.EXTERIOR ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP E 4 FIBERGLASS REINFORCED PLASTIC CORROSION ❑ gl NONE ❑95 UNKNOWN ❑ 99 OTHER PROTECTION ❑ 5 CATHODIC PROTECTION92 SPILL CONTAINME STALLED(YEAR) OVERFl L REVENTION EQUIPMENT INSTALLED(YEAR) E.SPILL AND OVERFILL,etc. DROPtr YES NO_ SX IKERPLATEYES NO_ DISPENSER CONTAINMENT VES_ NO IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION A E2 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL A&/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 Q 4 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL W/COATING A U 8 100% METHANOL COMPATIBLE WffRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER 1 IECN411UL LME IFAK 3 4 RE MTK+MNE58 CgmNWll9 INIERSIrtIAL CTILONIC UNE ❑5 A.U=TC RIMP ❑ D. LEAK DETECTION 2❑ �ODg ❑ resnx0 ❑ MDMraRNo ❑ IEAx oETEcroR sRurMraN 99 OTHER V.TANK LEAK DETECTION ED VISUAL CHECK ❑ 2 ERCOLI CILIATIONORY ❑ 3 MAODNOITORING ZE ❑ 4 GAUGWGAUTOMATIC TANK ❑ 5 MON TORINGGROUND TER ❑8 TESTIANNUAL NG 7 CONTINUOUS INTERSTITIAL ❑ g SIR ❑ 9 WEEKLY MANUAL E::]10 MONTHLY TANK ❑ 95 UNKNOWN ❑ 99 OTHER MONITORING TANK GAUGING TING VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PUCE) 1.ESTIMATED DATE MdDAWYR) 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 TANK OWNERS NAME DATE (PRIMED d SIDNATURE) LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY# TA® STATE I.D.# c. = PERMIT NUMBER PERMIT APPROVED SYMATE PERMIT EXPIRATION DATE THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A,UNLESS ACURRENT FORM A HAS BEEN FILED. FORM C MUST BE COMPLETED FOR INSTALLATIONS. THIS FORM SHOULD BE ACCOMPANIED BY A PLOTp FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE U ERGROUND STORAGETANKREGULATIONS FORMS (6-95) f -77 7 "