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STATE OF CALIFORNIA c'. s >' STATE WATER RESOURCES CONTROL BOARD ym :a UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B >r _ , I COMPLETE A SEPARATE FORM FOR/EACH TANK SYSTEM. MARK ONLY F-11 NEW PERMIT ❑ 3 RENEWAL PERMIT LJ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ON SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE ED TANK REMOVED I S DBA OR FACILITY NAME WHERE TANK IS INSTALLED: 1Zt (p r w I. TANK DESCRIPTION COMPLETE ALL ITEMS— SPECIFY IF UNKNOWN A OWNER'S TANK I.D.# # B. MANUFACTURED BY:lAwk z C. DATE INSTALLED(MOIDAYNEAR) &,41D. TANK CAPACITY IN GALLONS: O II.TANK CONTENTS IFA-11S MARKED,COMPLETE ITEM C. MOTOR VEHICLE FUEL ❑ 4 OIL B. C. ❑ 1e REGULAR UNLEADED 3 DIESEL ❑ 6 AVIATION GAS A. 2 PETROLEUM ❑ 60 EMPTY 1 PRODUCT ❑ 1b PREMIUM UNLEADED ❑ 4 GASAHOL ❑ 7 METHANOL ❑ 1c MIDGRADE UNLEADED ❑ 5 JET FUEL ❑ B M65 ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED ❑ 99 OTHER(DESCRIBE IN ITEM O.BELOM D. IF(A1)ISNOTMARKED, ENTER NAME OFSUBSTANCE 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 ❑ 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 ❑ 6 100% METHANOL COMPATIBLE W/FRP (PrimaryTank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER C.INTERIOR ❑ I RUBBER LINED �❑/2 ALKYD LINING ❑ 3 EPDXY UNING ❑ 4 PHENOLIC LINING LINING OR F15 GLASS LINING IyI 6 UNLINED ❑ 95 UNKNOWN E] 99 OTHER COATING IS LINING MATERIAL COMPATIBLES WITH 100% METHANOL? YES— NOLO D.EXTERIOR ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC CORROSION 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER PROTECTION ❑ 5 CATHODIC PROTECTION SPILL CONTAINMENT INSTALLED R) OVERFILL PREVENT) N OUIPMENI INSTALLED(YEAR) E.SPILL AND OVERFILL,6I0. DROP TUBE YES_ NO STRIKER PLATE YES_ 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 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION A U SINGLE WALL A U 2' DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND A 1 BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A U 4 FIBERGLASS PIPE CORROSION A 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL W/COATING A U 6 100% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER 1 MECWMGL UNE LEAN 2 MNf mO KSS 3 C NMWS IMMTIML ❑d ELECTRONIC UNE ❑5 Al MAI'W 99 OTHER D. LEAK DETECTION ❑ oETECTOR ❑ TESRNG ❑ MaraTORMO LPAN DETECTOR SHUITXWlN V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 MANUAL RECONCILIATION MONITORING ❑ 3 MONO ORING ❑ 4 GAUGING AUTOMATIC TANK ❑-yt�59 MON TORINGGROUND TER ❑6 TESTINGNUAL TANK ❑ 7 MON TOR U INTERSTITIAL ❑ 6 SIR ❑ 9 WEEKLY MANUAL ❑10 MONTHLY TANK`Z `5 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) 1.ESTIMATED DATE LAST USED(MO/DAYNR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES ❑ NO ❑ SUBSTAMATER NCE REMAINING GALLONS INERT ;IAL? THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MV KNOWLEDGE, IS TRUE AND CORRECT TANK OWNER'S NAME DATE (PRINTED 6 SIGNATURE) I, LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW G r ^ COUNTY# JURISDICTION# FACILITY# 6CL3+ OL+ STATE I.Dl ME] = PERMIT NUMBER PERMIT APPROVED BYIDATE PERMIT EXPIRATION DATE -424, IHAAI� THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORMA HAS BEEN FILED. FORM C MUST BE COMPLETED FOR INSTALLATIONS. THIS FORM FORMJ3 (6.95)SHOULD BE ACCOMPANIED BY A PLOT PILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE fRGROUND STORAGE TANK REGULATIONS FOR00348-R7