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STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B I COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ON SI ONE ITEM ❑ 2 INTERIM PERMIT ED d AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE 8 TANK REMOVED ❑ DBA OR FACILITY NAME WHERE TANK IS INSTALLED: ' I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN / B. MANUFACTURED BY: A OWNER'S TANK I.D.# /�`/ D. TANK CAPACITY IN GALLONS: O DATE INSTALLED(MO/DAYNEAR) b II.TANLIF(A.1) KCONTENTS IF A.1 IS MARKED.COMPLETE ITEM C. 8 REGUUR UN EADED ❑ 3 DIESEL ❑ 6 AVIATION GAS OTOR VEHICLE FUEL ❑ 4 OIL B. C lb PREMIUM UNLEADED ❑ 4 GASAHOL ❑ 7 METHANOL ❑ 60 EMPTY �1 PRODUCT ❑ 1°MIDGRADE UNLEADED 1:3 5 JET FUEL ❑ 0 M05 ETROLEUMHEMICALPRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED ❑ 99 OTHER(DESCRIBE IN REM D.BFLOW)C.A.S.#: NOT MARKED. EMER NAME OF SUBSTANCE STORED III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXESA,B.AND C.AND ALLTHATAPPLIES IN BOX D AND E ❑ i DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 5 INTERNAL BLADDER SYSTEM ❑ 95 UNKNOWN A, TYPEEM ❑ 4 SINGLE WALL IN A VAULT ❑ 99 OTHER SYSTEM 2 SINGLE WALL JkT B. TANK 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD Wl FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 8 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 0 100% METHANOL COMPATIBLE W/FflP (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER ❑ I RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING C.INTERIOR �UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER LINING OR ❑ s GLASS LINING � 1 COATING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES— NO)< D.EXTERIOR ❑ i POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC CORROSION91 NONE ❑95 UNKNOWN ❑ 99 OTHER PROTECTION ❑ s CATHODIC PROTECTION SPILL CONTAINMENT INSTALLED IY ) OVERFILL PREVENT) N UIPMENT INSTALLED(YEAR) E.SPILL AND OVERFILL,BIC. DROP TUBE VES_ NO STRIKEfl PLATE YES_ NO DISPENSER CONTAINMENT VES_ NO IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR 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 B. CONSTRUCTION A U 1 SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 85 UNKNOWN A U 99 OTHER C. MATERIAL AND A 1 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 B 100% METHANOL COMPATIBLE WIFRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER 1 MECNWICRL UNE LFAK 2 UNE nGMNE65 ❑3 WNnNUWAS INTERETRIAL ❑4 ELECTRONIC LINE ❑5 AUfOMAnc PUMP ❑99 OTHER D. LEAK DETECTION ❑ 9ETECTaR TESTING LwmTonwc LPAK OEIECT°xi00 V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK �2 MANUAL LIATIONINVENTORY 3 MONOITORING ❑ 4 GAUGINGAUTOMATIC TANK ❑5 MONITORINGROUNDWAG TESTINGTANK ❑ 7 MON TNUOU INTERSTITIAL ❑ B SIR ❑ 9 WEEKLY MANUAL ❑10 MONTHLY TESTING TANK 0 95 UNKNOWN ❑99 OTHER VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES E::] NO ❑ 1.ESTIMATED DATE LAST USED(MISUBSTANCE 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 (PRINTED d SIGNATURE) LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW Kpr, ll COUNTY# JURISDICTION# FACILITY#66 NZ 7 STATE I.D.# a 5 U & D s PERMIT NUMBER PERMIT APPROVED BYIDATE PERMIT EXP) LATION THIS FORM MUSTRENT FORM A HAS BEEN FILED. FORM C MUST BE COMPLETED FOR INSTAL SHOULD BE ACCOMPANIED BY AI PLOT PCATIONLE THIS FFORM ORM WITH THE UNLESS A LOCAL AGENCY MMJP}L�EEyMENTIINGG�THE AN GROUND STORAGE TANK REGULATIONS SI THIS FORM B (6-95) Le r�-a?- I v �`�'Q o'-// -/le .44ee