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STATE OF CALIFORNIA ,d STATE WATER RESOURCES CONTROL BOARD +` •g UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B , a I COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ONSITE ONE TEM 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE / 8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: illi-dF �R11✓ I Tl` C7 C117— L!1'ti I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A OWNER'S TANK I.D.M n!K �. / B. MANUFACTURED BY: p r'� C. DATE INSTALLED(MO/DAYNEAR) U 0 N D. TANK CAPACITY IN GALLONS: 2-SD-- I II.TANK CONTENTS IF A-1 IS MARKED,COMPLETE ITEM C. to REGUEM UNLEADED ❑ 3 DIESEL E] 6 AVIATIONGAS A 1 MOTOR VEHICLE FUEL ❑ d OIL B. C. ❑ 1b PREMIUM UNLEADED ❑ 4 GASAHOL ❑ 7 METHANOL ❑ 2 PETROLEUM ❑ 80 EMPTY �, 1 PRODUCT ❑ Ic MIDGRADE UNLEADED ❑ 5 JET FUEL ❑ B M85 ❑ 3 CHEMICALPRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE 2 LEADED ❑ 99 OTHER(DESCRIBE IN TEMO.BELOM D. IF(A1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A S.M 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 CR 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 (PHmary TNk) ❑ 9 BRONZE El 10 GALVANIZED STEEL 95 UNKNOWN ❑ 99 OTHER C.INTERIOR ❑ 1 RUBBER LINED O 2 ALKYD LINING6713 EPDXY LINING ❑ 4 PHENOLIC LINING LINING OR ❑ 5 GLASS LINING F-1 T1 8 UNLINED 95 UNKNOWN El 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 CORROSION 91 NONE �95 UNKNOWN ❑ 99 OTHER PROTECTION ❑ s CATHODIC PROTECTION ❑ SPILL CONTAINMENT INSTALLED(YEAR) OVERFlLL PREVENTION EQUIPMENT INSTALLED(YEAR)�Q. /✓n / E SPILL AND OVERFILL,M0. DROP TUBE YES__ NO STRIKER PLATE YES_ NO_ DISPENSER CONTAINMENT VES 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 A 099 OTHER B. CONSTRUCTION A U 1 SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A 095 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 5 ALUMINUM A U 6 CONCRETE A U 7 5 W/COATING A U B 100% METHANOL COMPATIBLE WIFRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION AUJ5 UNKNOWN A U 99 OTHER D. LEAK DETECTION ❑i MECHAMGLL LINE UUK 2 UQ GNTNESS E]3 CONTINUWS INTERSTGIAL ❑4 EU:CTNIXAC UNE ❑5 AUTCNA9C PUMP ❑ B9 GE =R ❑ TESTING MGMT ING Uw oE1 mm sxuToowN V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 RECOUAL CILIATIONORV ❑ 3 VAE MONITORING E] 4 AUTOMATGAUGING IC TANK ❑5 MONTORINGTER ❑6 TESTING ANNUALTANK ❑ 7 MON TOR U INTERSTITIAL ❑ 8 SIR ❑ 9 WEEK LY MANUAL ❑10 MOTESTINGHLY TANK ❑ 95 UNKNOWN ❑99 OTHER VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) 1.ESTIMATED DATE LAST USED(MO/DAY/YR) 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 ST OF MY KNOWLEDGE,IS TRUE AND CORRECT DATE r/ TANK OWNER'S NAME P (PRINTED&SIGNATURE) -MOMR1 K I t 0 Lt'4A / ( V LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NLABERdELOW COUNTY N JURISDICTION N FACILITY N �b TANK#Q 1 STATE I.DX m 3 1 a PERMIT NUMBER PERMIT APPROVED BYIDATE PERMIT FXPIR 10 PERMIT TE h 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 PLAIS THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS FORMS (6-95)