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L dl STATE OF CAUFORNIA 9 LA t- STATE WATER RESOURCES CONTROL BOARD �A 01 � pz UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B >o COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY NEW PERMIT O 3 RENEWAL PERMIT O 5 CHANGE OF INFORMATION O 7 PERMANENTLY CLOSED ON SITE ONE ITEM 2 INTERIM PERMIT El 4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE O B TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: —3 . /Y/ ,S. 6 7 3 - I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKCWN A OWNERS TANK I.D.#C B. MANUFACTURED BV: y I ivla oru t jo C. DATE INSTAU.ED(MOIDAY/YEAR) D. TANK CAPACITY IN GALLONS: / G 4- C� II.TANK CONTENTS IFA-1 IS MARKED,COMPLETE ITEM C. A. 1 MOTOR VEHICLE FUEL E] 4 OIL B. C. L REGUVJi UNLEADED O 3 DIESEL Q e AVIATION GAS 2 PETROLEUM a BO EMPTY Q 1 PRODUCT 10 PREMMM UNLEADED ❑ d GASAHOL 7 METHANOL le MIDGRADE UNLEADED 5 JETFUEL � B M8.5 3 CHEMICAL PRODUCT O 95 UNKNOWN El 2 WASTE 2 LEADED 99 OTHER(DESCRIBEW REND.BELOYY) D. IF(A7)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 ® 1 DOUBLE WALL O 3 SINGLE WALL WITH EXTERIOR UNER ❑ 5 INTERNAL BLADDER SYSTEM 0 95 UNKNOWN SYSTEM Q 2 SINGLE WALL Q 4 SINGLE WALL IN A VAULT El 99 OTHER B. TANK O I BARE STEEL a 2 STAINLESS STEEL 3 FIBERGLASS ®• 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL Q 5 CONCRETE O 6 POLYVINYL CHLORIDE 7 ALUMINUM F-1 B 100% METHANOL COMPATIBLE WIFRP (PI'M1Y Tank) ❑ 9 BRONZE Q 10 GALVANIZED STEEL 95 UNKNOWN O 99 OTHER C.INTERIOR 1 RUBBER LINED ��a 2 ALKYD UNING 3 EPDXY LINING O 4 PHENOLIC LINING LINING OR 5 GLASS LINING lyf 6 UNLINED 95 UNKNOWN 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES— C_ D.EXTERIOR O 1 POLYETHYLENE WRAP O 2 COATING 3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC CORROSION PROTECTION 5 CATHODIC PROTECTION Q 91 NONE E]95 UNKNOWN a 99 OTHER E SPILL AND OVERFILL,6h. SPILL CONTAINMENT If1STALLED(YEAR) -- OVERRLLPREVENTIN9OUIPMENTINSTALLED(YEAR) DROP TUBE YES Z" C_ TRIKER PLATE VES_ NO DISPENSER CONTAIN ME NT YES NO IV.PIPING INFORMATION CIRCLE A IFABOVEGROUNDOR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A 1 SUCTION - A U 2 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING 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) 4 FIBERGLASS PIPE CORROSION A U S ALUMINUM A U B CONCRETE A U 7 STEEL W/COATING A B 100X METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION 1 IECN/NGL ME 1FAIc O 2 N1E tnxnrss 3 OX+InApin wlpAmnu 0 a Bacmanc Ia+E s Mrtownc wuv O 99 OTHER DERCIOB TESTNn YSNiePN9 WR OETECICR 9MOOWN V.TANK LEAK DETECTION 1 VISUAL CHECK D 2 RECONCILIATIONNUAL ORY 3 MONITORING ZE 4 GAUGG AUTOMATIC TANK 5 MON TORINGOUND TER - TESTING 7 MONITORING CONTINUOUS INTERSTITIAL a B SIR 9 WEEKLY MANUAL 10 TONTH=SnGY TANK a g5 UNKNOWN 99 OTHER VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) 1.ES3.2.ESTIMATED QUANTITY OF� 3.WAS TANK FILLED WITH YES O NO Z.-- SUBSTANCE REMAINING GALLONS INERT MATERIAL i THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT TANK OWNER'S NAME j/ /J IPAME086K;NATURE) o //L z Z (/LL-1 6p LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY# TANK# STATE I.D.# m PERMIT NUMBER PERMIT APPROVED BYIDATE PERMIT EXPIRATION DATE 71 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 PLOT PLAN. FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS FORM 8 (6.95)