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STATE OF CALIFORNIA • STATE WATER RESOURCES CONTROL BOARD tV -`�� UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B ° ;Y� 1 C J COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY LZ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ON SITE ONE REM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE B TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: 8&-a-< Jcy I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A. OWNER'S TANK I.D.s >G/. 7 B. MANUFACTURED BY: C. DATE INSTALLED(MO•DAY%EAR) D. TANK CAPACITY IN GALLONS: ILTA�NKCONTENTS IFA-11S MARKED,COMPLETE ITEM C. p L'LJ 1 MOTOR VEHICLE FUEL ❑ • OIL B. C. ❑ 1AUNLEADED e 4 GASAHOL LAR 3 DIESEL ❑ 6 AVIATION GAS ❑ 2 PETROLEUM ❑ BO EMPTY L PRODUCT ❑ lbP UNLEADED 5 JET FUEL ❑ 7 METHANOL ❑ 3 CHEMICALPRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED JE� N OTHER (DESCRIBE IN ITEM D. BELOWI D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED UNLQ i E2'. uf- C.A.S.s: III. TANK CONSTRUCTION MARK ONE REM ONLY IN BOXES A.S.ANOC.AND ALLTHAT APPLIES IN BOK D AND A. TYPE OF [YJ 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM �❑ 2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER "� B. TANK � 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD WI FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ B 100% METHANOL COMPATIBLE W/FRP (PNm6ryTwk) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN 99 OTHER sA3.22LLi/..LSS S=G-�-•- ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING C.INTERIOR ❑ 5 GLASS LINING ❑ 6 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER LINING IS LINING MATERIAL COMPATIBLE WITH 100% MET14ANOL7 YES_ NO_ D.CORROSION ❑ I POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP A FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE 95 UNKNOWN 99 OTHER E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR) L OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) G7 Z IV,PIPING INFORMATION CIRCLE A IFABOVEGROUNDOR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SIX:TK]N A 2 PRESSURE A U 3 GRAVITY A U 99 OTHER S. CONSTRUCTION A U 1 SINGLE WALL A&2 DOUBLE WALL A U 3 LINED TRENCH A U 95 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 STEEL W/COATING AJOB IOD% METHANOL COMPATIBLE W[FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 25 UNKNOWN A U 99 OTHER D. LEAK DETECTION 1 AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING MONITORING ❑ 99 OTHER V.TANK LEAK DETECTION 7'❑ 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATI N �❑ 3 VADOZE MONITORING ❑ 4 AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING ❑ 6 TANK TESTING 7 INTERSTITIAL MONITORING ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION 1.ESTIMATED DATE LAST USED(MOIDAYNR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES ❑ NO SUBSTANCE REMAINING GALLONS INERT MATERIAL? THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURYIVWD TO THE BEST OF MY KNOWLEDGE. IS TRUE AND CORRECT APPLICANTS NAME DATE IPRINTEDA 6KiKATUREI /J /1 Z- LOCAL AGENCY USE ONLY THE STATE LD.N-UMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION r�FACILITY# TANK STATE I.D.# m I I_ I I I JJ I I I I I I I PERMIT NUMBER PERM IT APPROVED BYIDATE PERMIT EXPIRATION DATE FORM B (1.91) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. FORIXIMM