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STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY a 1 NEW PERMIT O 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ON SITE ONE ITEM ❑ 2 INTERIM PERMIT O 4 AMENDED PERMIT a 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: rvy-, 55 _ I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A OWNERS TANK I.D.M B. MANUFACTURED BY: G S C. DATE INSTALLED(MO/DAYNEAR) L312t 6 D. TANK CAPACITY IN GALLONS: j 57O II.TANK CONTENTS IF A-1 IS MARKED,COMPLETE ITEM C. p 1 MOTOR VEHICLE FUEL O 4 OIL B. C, 1a REGUWI UNLEAD® n`� 3 DIESEL ❑ 6 AVIATION GAS O 2 PETROLEUM O 80 EMPTY 1 PRODUCT ❑ 19 PREMAIM IMEAUFID u 4 GASAHOL ❑ 7 METHANOL E::] 3 CHEMICAL PRODUCT O 9S UNKNOWN 2 WASTE ❑ 1C MIDGRADE UNLEADED El 5 JET FUEL O 6 M85 ❑ 2 LEADED ❑ 99 OTHER(DESCRIBE N ITEM D.esuo ) D. IF(p1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S.8: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.S.AND C.AND ALL THAT APPLIES IN BOX D AND E A. TYPE OF Ll1 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 5 INTERNAL BLADDER SYSTEM O 95 UNKNOWN SYSTEM ❑ 2 SINGLE WALL ❑ 4 SINGLE WALL IN A VAULT ❑ 99 OTHER B. TANK ❑ I BARE STEEL O 2 STAINLESS STEEL EX3 FIBERGLASS O 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 8 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP (PNmary T-k) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER C.INTERIOR ❑ I RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING O 4 PHENOLIC LINING LINING OR ❑ 5 GLASS LINING �6 UNLINED ❑ 95 UNKNOWN O 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL.? YES_ NO_ D.EXTERIOR O 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP XI 4 FIBERGLASS REINFORCED PLASTIC CORROSION PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE ❑95 UNKNOWN ❑ 99 OTHER E SPILL AND OVERFILL,BIO. SPILL CONTAINMENT INSTALLED(Y RI OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) DROP TUBE YES NO� STRIKER PLATE YES NO DISPENSER CONTAINMENT YES J�NO IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND.BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION A 612 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL A 1612 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)AP PVC)A 4 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL W/COATING A U 8 10D% 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 ❑1 IECN m UNE U: O 2 LNE TIa1R W 3 COKnN NTTASL 4 BECIR UNE 5 AF MAnC PULP O OTHER pE moR TESINa MmTw1w [FId(oEl£CTCR SHUNCWN V.TANK LEAK DETECTION �( F-11 VISUAL CHECK Llni 2 RECONCILIATION CILIATIONNUAL ORY ❑ 3 MONIITORING OZE 4 GAUGING MONITORING TANK ❑ 5 GROUNDWAMONTORINGTER ❑ e ANNUAL TESTING 7 CONTINUOUS INTERSTITIAL ❑ 8 SIR ❑ 9 WEEKLY MANUAL O 10 MONTHLY TANK O 95 UNKNOWN O 99 OTHER 119 MONITORING TANK A LNG TESTING VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) 1.ESTIMATED DATE UST USED(MO/DAYIYR) 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 B OF MY KNOWLEDGE,IS TRUE AND CORRECT TANIE611MEN6 NAME DATE (PRINTED A SIGNATURE) O LOCAL AGENCY USE ONLY THE STATE I. .N BER IS COMPOSED OF THE FOUR NUMBERS BELOW EPERNCOUNTY M JURISDICTION M FACILITY 8 TANK T TATE 01 m RPERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE O THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-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' ''. RLE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THF""DERGROUND STORAGE TANK REGULATIONS FORM B (F95)