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Y 11 • STATE OF CALIFORNIA ""SOV,�r-, STATE WATER RESOURCES CONTROL BOARD �'�49 m o UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ❑ 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 [Lj_-8'FANK REMOVED Fo DBA OR FACILITY NAME WHERE TANK IS INSTALLED: 1 ' I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A OWNER'S TANK I.D.k I I B. MANUFACTURED BY: C. DATE INSTALLED(MO/DAYNEAR) 1 D. TANK CAPACITY IN GALLONS: QO II.TANK CONTENTS IF A-1 IS MARKED,COMPLETE ITEM C. p to REGULAR UNLEADED ❑ 3 DIESEL ❑ 6 AVIATION GAS 5:],�MOTOR VEHICLE FUEL F74 OIL a. 7C PRODUCT 115-PREMIUM UNLEADED ❑ 4 GASAHOL ❑ 7 METHANOL ❑ 2 PETROLEUM ❑ 80 EMPTY „`tCUGRADE UNLEADED ❑ 5 JET FUEL ❑ 8 M85 ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE 2 LEADED ❑ 99 OTHER(DESCRIBE IN ITEM D.BELOYO D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE 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 ❑ i LE 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 E�j<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 (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER C.INTERIOR ❑ 1 RUBBER UNED ❑ 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% METHANOL? YES— NO D.EXTERIOR ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC CORROSION PROTECTION ❑ 5 CATHODIC PROTECTION ED 91 NONE 5 UNKNOWN ❑ 99 OTHER E.SPILL AND OVERFILL,650. SPILL CONTAINMENT I LED(YEAR) OVERFILL PRE N EQUIPMENT INSTALLED(YEAR) DROP TUBE YES_ NO_ STRI ERPLATE YES_ NO DISPENSER CONTAINMENT YES NO IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OIICULIV UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION A 2 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION A 1 SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND ACU) 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 A U 8 100% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 LVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER D, LEAK DETECTION EllMECHAMCAL LINE UE ED 2 LINE TK WWSS O 3 CONUNUWS IWVSTRML 4 ELEWIONIL UNE O 5 AWOWnC PUMP a 99 OTHER DETECTOR TESTING MONITORING LEAK DETECTOR SHUTDOWN V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK 2 gECONCILIAT TEONORV ❑ 3 VADOZEMONITORING ❑ 4 GAUGING AUTOMATIC TANK ❑5 GROUND MONITORING TER ❑ 6 TESTINOTANK [ED 7 MON TORWG INTERSTITIAL ❑ 8 SIR ❑ 9 TWEEKLY ANK GAUGING TESTING ❑10 MONTHLY TANK ❑ 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) 1.ESTIMATED DATE LAST USED(MO/DAYNS) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES ED NO f SUBSTANCE REMAINING O GALLONS INERT MATERIAL? 0 LF THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY D TO THE BEST 4 MY KNOWLEDGE, IS TRUE AND CORRECT TANK OWNER'S NAM A ` DATE (PRINTED a SIGNATURE) Y nN�✓- P ?r 2 LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW U COUNTY# JURISDICTION# FACILITY# ��- ,1-7 TANK# STATE 01 m 5' 1111 PERMIT NUMBER PERMIT APPROVED BYIDATE PERMIT EXPIRATION DATE THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLI -FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. F UST BE COMPLETED FOR INSTALLATIONS.THIS FORM SHOULD BE ACCOMPANIED BY A PLOT PIWE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THIW OUND-SST7ORAGE�E TANK REGULATIO FORME (6 95) f�-' �i 61 MJ