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STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B 1�1 COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOe -QU ONE ITEM 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ '6 TEMPORARY TANK CLOSURE ❑ 86 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: �SC ^7-'_ I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A. OWNER'S TAN�D. B. MANUFACTURED BY:C. DATE INSTALLAYIYEAR} D. TANK CAPACITY IN GALLONS: II TANK CONTENTS IF A-1 IS MARKED,COMPLETE ITEM C. ❑ 1a REGULAR UNLEADED ❑ 3 DIESEL ❑ 6 AVIATION GAS A. 9 MOTOR VEHICLE FUEL ❑ 4 OIL B>:rl C." 1b PREMIUM UNLEADED ❑ 4 GASAHOL 7 METHANOL 2 PETROLEUM ❑ 80 EMPTYPRODUCT 1c MIDGRADE UNLEADED ❑ S JET FUEL ❑ B M85 ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED ❑ 99 OTHER(DESCRIBE IN ITEM D.BELOW) D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S. Ill. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A,B,AND C,AND ALL THAT APPLIES IN BOX D AND E F71 DOUBLE WALL a 3 SINGLE WALL WITH EXTERIOR LINER Li5 INTERNAL BLADDER SYSTEM ❑ 95 UNKNOWN A. TYPE OF SYSTEM ❑ 2 SINGLE WALL 4 SINGLE WALL IN k VAULT EJ 99 OTHER 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W!FIBERGLASS REINFORCED PLASTIC B. TANK MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM B 100% METHANOL COMPATIBLE WlFRP (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY UNING [j4 PHENCLIC LINING C.INTERIOR LINING OR 5 GLASS LINING ❑ 6 UNLINED ❑ 95 UNKNOWN ❑ 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 ( 95 UNKNOWN ❑ 99 OTHER PROTECTION ❑ 5 CATHODIC PROTECTION 91 NONE❑ SPILL CONTAINM NT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT 1NSTALLED(YEAR} E.SPILL AND OVERFILL,Etc. DROP TUBE YES NO STRIKER PLATE VES NO DISPENSER CONTAINMENT YES NO 1V.PIPING INFORMATION CIRCLE A IF ABOVEGROUND OR U IF UNDERGROUND,BOTH IF APPLICABLE A SYSTEM TYPE A U 1 SUCTION f.U2 2 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLEPIPING A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALLE7A 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,2)4 FIBERGLASS PIPE A U 7 STEEL W/COATING A U B 100% METHANOL COMPATIBLE WIFRP CORROSION A U 5 ALUMINUM A U 6 CONCRETE PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER 1 MECHANICAL LINE LEAK 2 HE TIGHTNESS 3 CONTINUOUS INTERSTITIAL 4 ELECTRONIC LINE 5 AUTOMATIC PUMP 99 OTHER M LEAK DETECTION ❑ DETECTOR TESTING MONITORING LEAK CETECTOR SHUTDOWN ❑ V.TANK LEAK DETECTION Y�l VISUAL CHECK ❑ 2 MANUALRECONCINVENTTIONORY ❑ 3 VA,DOMONIBRING ❑ 4 GAUGING AUTOMATIC TANK ❑ 5 MONTORINGOUND TER ❑ 5 TESTINGANNUAL CONTINUOUS INTERSTITIAL ❑ B SIR ❑ 9 WEEKLY GAUGINGANUAL ❑ 10 MO TESTING TANK ❑ 95 UNKNOWN ❑ 99 OTHER MONTORING `111.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) 1.ESTIMATED DATE LAST USED{MOIDAYNR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES ❑ NO El REMAINING GALLONS INERT MATERIAL. THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT DATE TANK OWNER'S NAME (PRINTED 6 SIGNATURE) ' LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW �, J 5 " COUNTY# JURISDICTION# FACILITY# 3 TANK# STATE 04 = UV5T�l � PERMIT NUMBER PERMIT APPROVED BYIDATE PERMIT EXPIRATION DATE 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 PL FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTINERGROUND STORAGE TANK REGULATIONS FORM B (6-95) q� j 9wq