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1 � � • �aV•cpy STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD ?a,� UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B 1 COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ❑ i NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION O 7 PERMANENTLY CLOSED G ONE REM El INTERIM PERMIT FD AMENDED PERMIT 6 TEMPORARY TANK CLOSURE 8 TANK REMOVED �o S-rX62L--7-, Z-016-=DBA OR FACILITY NAME WHERE TANK IS INSTALLED: G - - / '.K�1 I. TANK DESCRIPTION COMPLETE ALL ITEMS— SPECIFY IF UNKNOWN B. MANUFACTURED BY: A OWNER'S TANK I.D.# C. DATE INSTALLED(MO/DAY/YEAR) D. TANK CAPACITY IN GALLONS: II.TANK CONTENTS IF A-1 IS MARKED,COMPLETE ITEM C. to REGUUR UNLEADED ❑ 3 DIESEL ❑ 8 AVIATION GAS A 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C ib PREMIUM UNLEADED ❑ 6 GASAHOL ❑ 7 METHANOL �2 PETROLEUM ❑ 80 EMPTY � PRODUCT iG MIDGRADE UNLEADED ❑ 5 JET FUEL ❑ 8 M85 ❑ 3 CHEMICALPRODUCT ❑ 95 UNKNOWN 2 WASTE ❑ 2 LEADED ❑ 99 OTHER(DESCRIBE IN ITEM D.BELO" C.A.S.#: D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED. III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A,B.AND C,AND ALL THAT APPLIES IN BOX D AND E 1 DOUBLE WALL E::] 3 SINGLE WALL WITH EXTERIOR LINEfl ❑ 5 INTERNAL BLADDER SYSTEM E] 95 UNKNOWN A. TYPE OF ❑ 99 OTHER SYSTEM 2 SINGLE WALL 4 SINGLE WALL IN A VAULT 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B. TANK MATERIAL 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBL (Primary Tank) 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING C.INTERIOR ❑ LINING OR ❑ 5 GLASS LINING ❑ 8 UNLINED 95 UNKNOWN 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 1001% METHANOL? VES_ NO— D.EXTERIOR El ' POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC CORROSION ❑ 95 UNKNOWN ❑ 99 OTHER PROTECTION 5 CATHODIC PROTECTION ❑ gt NONE SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) E.SPILL AND OVERFILL,etc. DROP7UBE YES___ NO STRIKER PLATE VES_ NO_ DISPENSER CONTAINMENT YES_ NO IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL 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) 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 1 MECR?NICAL ONE LEAX 2 UNE TIGHTNESS ❑3 CGN9N000S arrEASMW ❑4 RE LWK�CO UNE [:]5=PUMP ❑ 99 OTHER D. LEAK DETECTION ❑ D croft ❑ MTRIG uoreroRlxG V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 MANUAL INVENTORY ❑ 3 MONO ORING 4 GAUGING AUTOMATIC TANK ❑ 6 GROUND MONITORING TESTING ❑ e ANNUALTESTINGTANK RECONCILIATION O 7 MOESTING NTORWG INTERSTITIAL ❑ 8 SIR 9 TANKLY MANUAL ❑10 MONTHLY TANK ❑ 95 UNKNOWN 99 OTHER VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PUCE) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH VES ❑ NO E]1.ESTIMATED DATE LAST USED(MO/DAVlYR) SUBSTANCE REMAINING GALLONS INERT MATERIAL? 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 (PRINTED 8 SIGNATURE) LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY# TANK# r�_7,�7— STATE I.D.# Ur-r�'F J� aIIJ�LI I JI PERMIT NUMBER PERMIT APPROVED SYIDATE PERMIT EXPIRATION DATE THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLI ION-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. F MUST BE COMPLETED FOR INSTALLATIONS. THIS FORM SHOULD BE ACCOMPANIED BY A PLOT FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING TH RGROUND STORAGE TANK REGULATIONS FORMS (6-95)