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�1�pr uL STATE OFCAUFORNIA `` �� " ,o I STATE WATER RESOURCES CONTROL BOARD yam y' UNDERGROUND STORAGE TANK PERMIT APPLICATION -FORM B �y COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. to e MARK ONLY NEW PERMIT ❑ 3 RENEWAL PERMIT a 5 CHANGE OF INFORMATION ❑ T PERMANENTLY CLOSED ON SITE ONE ITEM 2 INTERIM PERMIT ❑ a AMENDED PERMIT ❑ 8 TEMPORARY TANK CLOSURE O B TANK REMOVED DBA OR FACILDY NAME WHERE TANK IS INSTALLED: I. TANK DESCRIPTION COMPLETE ALL ITEMIS- SPECIFY IF UNKNOWN //� ff � A OWNERS TAMC I.0.• B. MANUFACTURED BY: CAIp YL C,c 1`U/.✓ K�YJ+Ca. G DATE INSTALLED(MCMAYNEAR) 19009 0. TANK CAPACITY IN GALLONS Q / It.TANK CONTENTS IF MI IS MARKED,COMPLETE ITEM C. A 1 MOTOR VEHICLE FUEL ❑ ♦ OIL B. Q tI REGUIM IA�FADED ❑ 3 DIESEL ❑ a AVIATION GAS '❑ 2 PETROLEUM ❑ 80 EMPTY ❑ t PRODUCT lb PRDYIM UNIEAUB] ❑ 4 GASAMOL � T METHANOL to MDGRADE UNLEADED 5 JET FUEL B M85 ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE 2 LEADED 99 OTHER(DESCRGEPI ITE810.BELOM D. IF(A.1)IS NOT MARKED. ENTER NAME OFSUBSTANCE STORED GASP: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXESA,B.AND C.AND ALLTHATAPPUES IN BOX 0 ANO E A TYPE OF ['�ZI�' I DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ED INTERNAL BLADDER SYSTEM E] 95 UN104OWN SYSTEM LJ 2 SINGLE WALL ❑ a SINGLE WALL IN A VAULTI❑� 99 OTHER B. TANK f7I BARE STEEL. ❑ 2 STAINLESS STEEL [:] 3 FIBERGLASS I T-Y 4 STEE..CLAD W1 FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 8 POLYVINYL CHLORIDE ❑ T ALUMINUM ❑ 8 100% METHANOL COMPATIBLE WUFRP TM"Tisk) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER C.INTERIOR ❑ 1 RUBBER UNED ❑ 2 ALKYO LINING O 3 EPDXY LINING ❑ 6 PHENOLIC UNING LINING OR ❑ 5 GLASS LINING 8 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER L COATING IS UNING MATERIAL COMPATIBLE WITH 100%METHANOL? YES_ NO— D.EXTERIOR ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP 3 FIBERGLASS REINFORCED PLASTIC CORROSION PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE Q 95 UNKNOWN 99 OTHER E.SPILL AND OVERFILLeRe. SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION 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 APPUCA13LE A. SYSTEM TYPE A,W i C.CIJC A U 2 PRESSURE A U 3 GRAVITY A U s. FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL A OOU8LE WA A U 3 UNED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND A U 1 BARESTEE. A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A U L FIBERGLASS PIPE CORROSION A U 3 ALUMINUM A U 8 CONCRETE A U T STEEL WU COATING A U 8 100% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U M OTHER D. LEAK DETECTION I �'"'ix uc TEAT{ ❑z of 11p1I1FSt ❑3 Nlnu9ue PlRieilnLL ❑a BECTBnIc Inc ❑s AumKLne PIM ❑ �� ctTccRw Resm+9 BawlaBw rsM D[TTCRaR s.noox� V.TANK LEAK DETECTION 1 VISUAL CHECK ❑ 2 RECONCILIATION ANUAL ❑ 3 VADOZEMONITORING ❑ a GAUGING AUTOMATIC TANK ❑5 GROUND MONITORING ❑e ANNUALTESTING T CONnNNUO�INTFASTTTIAL ❑ a SIR ❑ 9 WE K LY MANUAL❑10 MONTHLYGING TESTING TANK Q 95 UNKNOWN ❑99 OTHER VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACET 1.ESTIMATETE USED(MO/DAV/YfR-T2- ESTIMATED QUANTITY OF� 3.WAS TANK RUED WITH 1.ESTim7Wr(MOlOAY/YR) VES ❑ NO SUBSTANCE REMAINING GALLONS INERTMATERIAL7 THIS FORM HAS SEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT TANK OWNERS NAME _/J /J DATE / O� (PRM®A9GNSTURE'B o/�EVATE Z '7 V.7�L fY(/1h/ LOCAL AGENCY USE ONLY I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY✓f JURISDICTION I FACILITY I TANK k STATE I.D.4 m PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE THIS FORM MUST BE ACCOMPANIED BY A PERLHT APPLICATION•FORM A.UNLESS A CURRENT FORM A HAS BEEN MO. FORM C MUST BE COMPLETED FOR INSTALLATIONS THIS FORM' SHOULD BE ACCOMPANIED BY A PLOT PLAN. RLE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS FORM B(693)