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N� >_y D ISC�V��J �i>�►J� STATE OF CAUFORNIA • �� `. STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B e; 1 COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY I NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSEkONSITE ONE REM 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORAR,Y�T,A,NK/CLOSURE S TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED /0'V '� e'� R� �TI. TANK DESCRIPTION COMPLETE ALL ITEMS— SPECIFY IF UNKNOWNA ' ) A OWNER'S TANK I.D.R U N ^ .�/ B. MANUFACTURED BY: U i�/ C. DATE INSTALLED(MO/DAY/YEAR) U �KIN6 yA/h D. TANK CAPACITY IN GALLONS: II.TANK CONTENTS IF A-1 IS MARKED,COMPLETE ITEM C. 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C. fa REGULAR UNLEADED ❑ 3 DIESEL ❑ 6 AVIATION GAS A "` "' 2 PETROLEUM ❑ 80 EMPTY �1 Ic MIDGRADE UNLEADED 5 JETFUEL PRODUCT ❑ lb PREMIUM UNLEADED ❑ 4 GASAHOL [:] 7 METHANOL ❑ ❑ ❑ E] 8 M85 ❑ 3 CHEMICALPRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ® 2 LEADED ❑ 99 OTHER(OESCRIBE IN ITEM D.BELOWI D. IF(AI)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S.0: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.B.AND C.AND ALL THAT APPLIES IN BOX 0 AND E A. TYPE OF ❑ 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 5 INTERNAL BLADDER SYSTEM 5�f95 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 (Primly Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL 95 UNKNOWN ❑ 99 OTHER C.INTERIOR ❑ 1 RUBBER LINED ❑ 2 ALKYD UNING ❑ 3 EPDXY UNING ❑ 4 PHENOLIC LINING LINING OR ❑ 5 GLASS LINING ❑ 6 UNLINED 95 UNKNOWN ❑ 99 OTHER COATING IS UNING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO— D.EXTERIOR ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC CORROSION g1 NONE 95 UNKNOWN E] 99 OTHER PROTECTION ❑ 5 CATHODIC PROTECTION F] SPILLCONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) E.SPILL AND OVERFILL,81C. DROP TUBE VES_ NO. STRIKER PLATE YES_ NO_ DISPENSER CONTAINMENT YES 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 AU 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A®95 UNKNOWN A U 99 OTHER C. MATERIAL AND A U I 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 W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A6)95 UNKNOWN A U 99 OTHER - I M:CKWICAL UNE!FM 2 LIRE TIGN1NESa 3 CON1NUWa IHfBiE11IlAL04=%.C UNE 5 AV0MA=PaW gg OTHER D. LEAK DETECTION ❑ gE1EaoR ❑ m nND ❑ MwarcRlxo ElEctoB ❑ sxUroovm V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 RECO CIUATIONORV ❑ 3 MAODNIIOZETORING ❑ 4 GAUGNGAUTOMATIC TANK ED5 MONITORINGGROUND TER ❑ 8 TESTING ❑ 7 MONITORINGCONTINUOUS INTERSTITIAL ❑ 8 SIR ❑ 9 WEEKLY MANUAL ❑ 10 MONTHLY TANK 95 UNKNOWN ❑ 99 OTHER NG 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 INERT MATERIAL? THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO TH BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT TANK OWNER'S NAME (/LZT— I DATE / (PRINTED 6 SIGNATURE) R (A I�t O l LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOU NUMBERS LOW COUNTY# JURISDWICTION JM FACILITVM - TANK#0/.1 STATE I.D:# 1 l PERMIT NUMBER PERMIT APPROVED BYIDATE PERMIT EXPIRATION DATE THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPUCATION-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED, FORM C MUST BE COMPLETED FOR INSTALLAYIONt.THIS FORM SHOULD BE ACCOMPANIED BY A PLOT PLAW THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNjGROUND STORAGE TANK REGULATIONS FORM B (&95)