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►VES L_y 'bISGovt-TQEj) TAa,)C • STATE OF CALIFORNIA • W^CC s STATE WATER RESOURCES CONTROL BOARD yds . UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B - I 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 REM ID2 INTERIM PERMIT El4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE B TANK REMOVED O DBA OR FACILITY NAME WHERE TANK IS INSTALLED: PI �!�I-RN I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A OWNER'S TANK I.D.# UNK/v Vw B. MANUFACTURED BY: u Aj C. DATE INSTALLED(MO/DAYNEAR) U "6*11IJ D. TANK CAPACITY IN GALLONS: `L. — ILTANK CONTENTS IFA-1 IS MARKED.COMPLETE ITEM C. ❑ C. 1e REGULAR UNLEADED 3 DIESEL ❑ 8 AVIATION GAS A � 1 MOTOR VEHICLE FUEL 4 OIL B. 2 PETROLEUM BO EMPTY 1 PRODUCT ❑ 1b PREMIUM UNLEADED Ej 4 GASAHOL ❑ 7 METHANOL ❑ ❑ ❑ is MIDGRADE UNLEADED ❑ 5 JETFUEL ❑ 8 M85 ❑ 3 CHEMICALPRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED ❑ 99 OTHER(DESCRIBE IN ITEM D.BELOM D. IF(AI)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 ❑ 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 5 INTERNAL BLADDER SYSTEM 2g 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 ❑ B 100% METHANOL COMPATIBLE W/PRP (Prim6ryT#RW ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL 95 UNKNOWN ❑ 99 OTHER C.INTERIOR ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY UNING ❑ 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 CORROSION91 NONE I�95 UNKNOWN ❑ 99 OTHER PROTECTION ❑ 5 CATHODIC PROTECTION ❑ JG4 SPILLCONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) E.SPILL AND OVERFILL,etc. DROP TUBE VES_ NO_ STRIKER PLATE VES_ NO_ DISPENSER CONTAINMENT Y IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING U 9 OTHER B, CONSTRUCTION A U 1 SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A 05 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 S 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 U 5 UNKNOWN A U 99 OTHER i LECXAl11CA'.LME LMN 2 UNE TEiM1 % 3 C NUW3 MI'ePSTIBAL 4 ELECIRDMC J. ❑5 AMOMBC NIF gg OTHER D. LEAK DETECTION ❑ oETECTD9 ❑ TEm99 ❑ MDNm m ❑ Uw D cr sNur9Dwn V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 RECONCILIATIONORV ❑ 3 MONTANK VAOZEIITORING ❑ 4 AUTOMATIGAUGING TANK ❑ 5 GROUND MONTORINGTER ❑6 ANNUALTESnNG ❑ 7 k OrNU UG INTERSTITIAL ❑ 8 BIR ❑ 9 TANK LAUGINGAL ❑10 M SNTIT}N1GV TANK �g5 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) 1.ESTIMATED DATE LAST USED(MO/DAV/YR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES ❑ NO ❑ SUBSTANCE REMAINING GALLONS I INERT MATERIAL? THIS FORM HAS BEEN COMPLETED UNDER PENALTY/OF PERJU Y,AND TO T E BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT TANK OWNER'S NAM bo& T IKL LSi,T/ (--f -S'w"RfE\/ I \ DATE, 2--U-11 (PRINTED 6 SIGNATURE) l/ LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FO A NUMB BELOW COUNTY# JURISDICTION# FACILITY#3 G''7 TANK# p STATE I.D.# m I A 3 PERMIT NUMBER PERMIT APPROVED BYIDATE PERMIT EXPIRATIO DATE 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 FLAW THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNqERGROUND STORAGE TANK REGULATIONS FORM B (EBS)