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& 121 I�I13IflN o•„„,.. STATE OF CALIFORNIAI� :• 4 0 STATE.WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION -FORM B 3, t I COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY I NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED ON SITE ONE REM 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 8 TEMPORARY TANK CLOSURE 8 TANK REMOVED DBA OR FACILRYNAME WHERE TANK ISINSTALLED: Lo Pk a3 s I. TANK DESCRIPTION COMPLETE ALL ITEMS– SPECIFY IF UNKNOWN A OWNERS'TANK I.D. 3 T� psg) / b B. MANUFACTUREBY; D. TANK CAPACITY IN GALLONS: C. DATE INSTALLED(MO/OAYf/EAR) ., II.TANK CONTENTS IF A-1 1S MARKED,COMPLETE REM C. a REGULAR UNLEADED 3 DIESEL ❑ 8 AVIATION GAS A 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C. ❑ lb PREMIUM UNLEADED 4 GASAHOL ❑ 7 METHANOL ❑ 2 PETROLEUM ❑ SD EMPTY ❑ I PRODUCT ❑ IC MIDGRADE UNLEADED ❑ 5 JET FUEL ❑ 8 MBS ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED ❑ 99 OTHER(DESCRIBE IN ITEM D.SELOM 3 CHEMICAL PRODUCT � D. IF(0.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STOPED C.A S K III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A 8,AND C.AND ALL THAT APPUES IN BOX D AND E ❑ 1 DOUBLE WALL ❑ 3SINGLE WALL WITH EXTERIOR UNER ❑ 5 INTERNAL BLADDER SYSTEM ❑ 95 UNKNOWN A. TYPE OF ❑ 4 SINGLE WALL IN A VAULT ❑ 99 OTHER SYSTEM .E3?4 SINGLE WALL „�LI BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B. TANK ❑ e POLYVINYL CHLORIDE E] 7 ALUMINUM 8 100% METHANOL COMPATIBLE W/FRP 5 CONCRETE MATERIAL ❑ (PdMMYTenk) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER 1 RUBBER UNED ❑ 2 ALKYD UNING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING C.INTERIOR �95 UNKNOWN ❑ 99 OTHER LINING OR ❑ 5 GLASS UNING ❑ 8 UNLINED COATING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES— NO— D.EXTERIOR ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING 3 VINYL WRAP ❑ 4' FIBERGLASS REINFORCED PLASTIC CORROSIONx}/91 NONE E]95 UNKNOWN 99 OTHER PROTECTION ❑ 5 CATHODIC PROTECT1ON-9 SPILL CONTAINMENT INSTAU.ED(YEAR) OVERFILL PREVENTION EQUIP DISPENSER CONTAINMENT YES__ NO—_ E SPILL AND OVERFILL,eta. DROPTUBE YES_ NO STRIKERPLATE YES__ NO_ IV.PIPING INFORMATION CIRCLE A IFABOVEGROUNDOR U IFUNDERGROUND,BOTH IFAPPUCABLE A. SYSTEM TYPE A U Su A U 2 PRESSURE A U 3 GRAVITY A U a FLIXIBLEPIPING- A' U 99 OTHER B. CONSTRUCTION A U SINGLE W A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND A U 1 BAR A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A U 4 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 8 CONCRETE A U 7 STEEL W/COATING A U a 100% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER 1 uEuuwcu u9s LFAX 2 UKs R9KIIEss ❑3 ca iImw,wlswlm4l. ❑4 BEORWO UI2 ❑5 AS N W11P ❑ 99 0T izR D. LEAK DETECTION h B P WORM ms's ❑ pElEOTOP V.TANK LEAK DETECTION 2 MANUAL INVENTORY ❑ 3.MONITORING ❑ 4 GAUODING C TANK L::3 5 GROUND MONITORING ❑ B TESTING ❑ 1 .VISUAL CHECK ❑ RECONCIUAT10N 7 CONTINUOUS INTERSTITIAL 8 SIR ❑ 9 TAFNK GAUGINGAL ❑10 TESTTIINGY TANK El OTHER UNKNOWN , MONRORING VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) 3 WAS TANK FILLED WITH YES ❑ NO 2 ESTIMATED QUANTITY OF �CALLONS INERT MATERIAL7 I.ESTIMATED DATE LAST US �(MO/OAYIYR) SUBSTANCE REMAINING THIS FORM HAS BEEN COMPLETED UNDER PENAfYOPERJ RY,AND TO THE BEST OF MY KNOWLEDGEEIS TRUEANDCORRECT LOCAL AGENCY USE ONLY THE STATE I.O.NUMBER IS COMPOSED OFTHE FOUR NUMBERS BELOW Tyr# ' COUNTY N JURISDICTION A FACILITY M STATE I.D:# m [� PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE D FOR THIS FORM MUSTSHOULD BE ACCOLMPANIED BY AL PLOT PLAN. FILEFTHIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE U UNDERGROUND STORAGEENS. THIS FORM ORM A,UNLESS A FORMA HASBEENFILED. FORM C MUST BE TANK REGULATIONS