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STATE OF CALIFORNIA b STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B 3 - i COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION R7 PERMANENTLY CLOSEDQO ONE REM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE B TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: ' - u, wP I, TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A OWNER'S TANK I.D.N B. MANUFACTURED BY f, VLkhe C. DATE INSTALLED(MOIDAY/YEAR) -- V D. TANK CAPACITY IN GALLONS: n crov p 10 II.TANK CONTENTS IF A-1 IS MARKED,COMPLETE ITEM C. 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C. 1e REGULAR UNLEADED ❑ 3 DIESEL ❑ 6 AVIATION GAS A ❑ 1C PREMIUM UNLEADED ❑ 4 GASAHOL ❑ 7 METHANOL ❑ 2 PETROLEUM ❑ BO EMPTY PRODUCT ❑ Ic MIDGRADE UNLEADED ❑ 5 JET FUEL ❑ 8 M85 ❑ 3 CHEMICALPRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED ❑ 99 OTHER(DESCRIBE IN REM D.BEI-OW) 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 F7I DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 5 INTERNAL BLADDER SYSTEM E:] 95 UNKNOWN SYSTEM 2 SINGLE WALL ❑ 4 SINGLE WALL IN A VAULT ❑ 99 OTHER 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W1 FIBERGLASS REINFORCED PLASTIC B. TANK MATERIAL ❑ 5 CONCRETE ❑ 8 POLYVINYL CHLORIDE ❑ ] ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP (Pflm"T6nk) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER C.INTERIOR ❑ I RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING LINING OR ❑ 5 GLASS LINING 8 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES— N04 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 CO NTAINMENT INSTALLED EAR) '14 OVERFILL PR VENT! N EQUIPMENT INSTALLED(YEAR) �( E.SPILL AND OVERFILL,etc. DROPTUBE 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 1 SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND Al V�I 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 8 100% METHANOL COMPATIBLE WIFRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER 1 IEGWdGL UNE LEAK 2 UNE TN90NE56 3 COmINUWS IH1EfL511IlAL ❑4 ELECIRDXIC UNE ❑5 AUTOIMBO PUMP ❑ 99 OTHER D. LEAK DETECTION ❑ �� ❑ U* ❑ M NIJIXS ZMc DE1ECTDR sluToovm V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK �2 RECONCILIIATIONORY ❑ 3 MONIITORING ❑ 4 AUTOMATGAUGING MONITORING TANK ❑ 5 GROUND MONTORINGTER 8 TE�NGTANK a 7 CONTINUOUS INTERSTITIAL ❑ B SIR ❑ 9 WEEKLY MANUAL ❑ 10 MONTHLY TANK ❑ 95 UNKNOWN ❑ 99 OTHER MONITORING VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) 1.ESTMA D DATE LgST USED(MO(D V/YR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES ❑ NO 3 _ 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 (PRINTED861GNATURE) _l —7 / LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW -e I / 7 C COUNTY# JURISDICTION N FACILITY U TANK# STATE I.D.# �' [� PERMIT NUMBER PERMIT APPROVED BY/DATE 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 INSTALLAT IS FORM SHOULD BE ACCOMPANIED BY A PLOT P .-FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE RGROUNDSTORAGETANK REGULA FORM (6.95) '