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STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD ,'c UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. 1 MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION n 7 PERMANENTLY C OC/ONE ITEM ❑ 2 INTERIM PERMIT L-14 AMENDED PERMIIT` ❑ 6 TEMPORARY TANK CLOSURE urs 8 TANK REMOVED O C/ DBA OR FACILITY NAME WHERE TANK IS INSTALLED: 15 4,�p 3 , 52 to C I. TANK DESCRIPTIONCOMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A OWNER'S TANK I.D.Y / (' B. MANUFACTURED BY: C. DATE INSTALLED(MO/DAYNEAR) (/�N v- D. TANK CAPACITY IN GALLONS: If.TANK CONTENTS IF A-1 IS MARKED,COMPLETE ITEM C. A, ❑ 1 MOTOR VEHICLE FUEL ❑ 4 OIL B, C. 1a REGULAR UNLEADED ❑ 3 DIESEL ❑ 6 AVIATION GAS ❑ 2 PETROLEUM ❑ 80 EMPTY �1 PRODUCT ❑ 1b PREMIUM UNLEADED ❑ 4 GAS OL ❑ 7 METHANOL ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 1C MIDGRADE UNLEADED O 5 JET FUEL ❑ 8 M85 ❑ 2 LEADED ❑ 89 OTHER IOESCRJOE IN ITEM D.BELOW) D. IF(A.1)IS NOT MARKED, ENTER NAME OFSUBSTANCE STORED C.A.S.k Ill. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.B,AND C.AND ALL THAT APPLIES IN BOX D AND E 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 1 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 (Pdm ry 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 6 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 100-. METHANOL? YES_ NO— D.EXTERIOR ❑ 1 POLYETHYLENE WRAP1�1 2 COATING3 VINYL WRAP CORROSION ❑ 4 FIBERGLASS REINFORCED PLASTIC ❑ PROTECTION ❑ 5 CATHODIC PROTECTION - 91 NONE ❑95 UNKNOWN ❑ 99 OTHER E.SPILL AND OVERFILL,etc. SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) DROP TUBE 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 A U--I SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION A U41 SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND U 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 WIFRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION ❑1 NECWNIGL UNE Ui ❑2 INE MMKIXMI; ❑3 nNuws N1En5TRML ❑4 BEC9WNIC UNE ❑s AUTOMATIC PUMP 9En:Cfgi iEanNG c MGNIDRMD ITM OETECT011 3HUl9pNTl ❑ 99 OTHER V.TANK LEAK DETECTION ❑ i VISUAL CHECK ❑ 2 MANUAL INVENTORY ❑ 3 VAMOMOTZE ORING E:] 4 AUTOMAT GAUMGMONITORING TANK ❑5 ND WATER ❑6 ANNUAL TANK ❑ 7 MONITORING S INTERSTITIAL ❑ 8 SIR ❑ 9 WEEKLY MANUAL D1 MONTHLY TANK 9S UNKNOWN TANK GAUGING TESTING ❑ ❑ 98 OTHER VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) 1.ESTIMATED DATE LAStSE=NR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH SUBSTANCE REMAINING GALLONS INERT MATERIAL? YES ❑ NO THIS FORM HAS BEEN qOMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND/CORRECT TANK OWNERS NAME `p /. / (PRINTED4SIGNATURE)- M.L'L[ P 1� '��(� �•n� / DATE I �/ LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW /til COUNTY M JURISDICTION k FACILITY k T NK e STATE I.D:# m PERMIT NUMBER PERMIT APPROVED BYIDATE PERMIT EXPIRATION DATE THIS FORM MUST BE ACCOMPANIED BY A PERMIT AP PLICATION-FORM A,UNLESS A CURRENT FORMA HAS BEEN FILED. FORM C MUST BE COMPLETED FOR INSTALLATIONS.THIS FORM SHOULD BE ACCOMPANIED BY A PLOT PLWILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE*GROUND STORAGE TANK EGULATN�„n FORM B (6-95)