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' 0 you n�tg i STATE OF CALIFORNIA r c°ti STATE WATER RESOURCES CONTROL BOARDbib UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B •C�k YIOn y� COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ,,,��❑--.��------,,,/��'�11 NEW PERMIT F73 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION F–] 7 PERMANENTLY CL S ONEITEM INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: ig, , I. TANK DESCRIPTION COMPLETE ALL ITEMS– SPECIFY IF UNKNOWN A. OWNER'S TANK I.D.q MANUFACTURED BY: 6(sQ C. DATE INSTALLED(MOIDAYIYEAR) D. TANK CAPACITY IN GALLONS: 6 1I 000 II.TANK CONTENTS IF A-1 IS MARKED,COMPLETE ITEM C. A. 1 MOTOR VEHICLE FUEL F74 OIL B. C. ❑ 1a REGULAR UNLEADED ❑ 3 DIESEL ❑ 6 AVIATION GAS 2 PETROLEUM ❑ BO EMPTY 1 PRODUCT ❑ 1b PREMIUM UNLEADED E::] 4 GASAHOL ❑ 7 METHANOL I MIDGRADE UNLEADED ❑ 5 JET FUEL ❑ 8 M86 ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED ❑ 99 OTHER(DESCRIBE IN TEM D.BELDV4) D. IF(A.1)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 THATAPPLIES 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 ❑ B ICO% METHANOL COMPATIBLE WIFRP (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER C.INTERIOR ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING LINING OR ❑ 5 GLASS LINING ❑ 6 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 100°,6 METHANOL? YES— NO— D.EXTERIOR ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC CORROSION PROTECTION ❑ S CATHODIC PROTECTION ❑ 91 NONE ❑95 UNKNOWN ❑ 99 OTHER E.SPILL AND OVERFILL Bt0 SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL REVENTIQN EQUIPMENT INSTALLED(YEAR) + 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 I SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION A U I SINGLE WALL A U 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(PUC) U 4 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEELWICOATING A U B 100% METHANOL COMPATIBLE WIFRP PROTECTION A U 9 GALVANIZED STEEL A U IO CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER 1 MECHANICAL LINE LEAK X2 LINE TIGHTNESS 3 CONTINUOUS 1NTERSTITIAt 4 ELECTRONIC LINE 5 AUTOMATIC PUMP 99 OTHER D. LEAK DETECTION ❑ DETECTOR TESTING MCNITORENG LEAK DETECTOR SHUTDOWN ❑ V.TANK LEAK DETECTION 1 VISUAL CHECK ❑ 2 RECONCILIATION MONITORING ❑ 3 MONIITORING ❑ 4 AUTGAUGING TANK MANUAL VADOZEGING�TIC TANK ❑ 5 GROUND MONITORING ❑ 6 ANNUALTESTING 7 CONTIINUOUS MONITORING INTERSTITIAL ❑ 8 SIR E] TpNEKGAUGAINGAL ❑IO TMES NGLY TANK EL] UNKNOWN ❑99 OTHER I,TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) 1.ESTIMATED DATE LAST USED{MOIDAYIYR) 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 THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT TANK OWNER'S NAME ` + / DATE (PRINTED881GNATVRE} J /6 i J 7 /- LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW �-lb a,3 ! I-5& COUNTY# JURISDICTION# FACILITY# TANK# STATE I.Dl m pti } 16_ 10ticr�lllol 7 PERMIT NUMBER PERMIT APPROVED BYlDATE PERMIT EXPIRATION DATE p, 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 PLO FILE THIS FORM YWITH THE LOCAL AGENCY IMPLEMENTINGJRGROUND STORAGE TANK REGULATIONS FORM B (6-95)