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' sou Ar. y c STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B 1 '11" wl. 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 ❑ 4 AMENDED PERMIT a 6 TEMPORARY TANK CLOSURE 8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED. J _ f f(4VY�1 I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A OWNER'S TANK I.D,# B. MANUFACTURED BY: C. DATE INSTALLED(MOIDAYNEAR) D. TANK CAPACITY IN GALLONS: no Il,TANNK�I CONTENTS IF A-1 IS MARKED,COMPLETE ITEM C. A. yl 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C ❑ is REGULAR UNLEADED ❑ 3 DIESEL ❑ 6 AVIATION GAS +❑ 2 PETROLEUM ❑ 80 EMPTY 1 PRODUCT El1b PREMIUM UNLEADED ❑ 4 GASAHOL ❑ 7 METHANOL ❑ 1c MIDGRADE UNLEADED ❑ 5 JET FUEL ❑ 6 U85 ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE 2 LEADED ❑ 99 OTHER(DESCRIBE IN ITEM O.BELOW] D. IF(A.i)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C-A.S.# 111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A,B,AND C,AND ALL THAT APPLIES 1N BOX D AND E A. TYPE OF ❑ 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 5 INTERNAL BLADDER SYSTEM ❑ 95 UNKNOWN SYSTEM 2 SINGLE WALL ❑ 4 SINGLE WALL IN A VAULT ❑ 99 OTHER B. TANK 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE WIFRP {Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNCWN ❑ 99 OTHER C.INTERIOR ❑ 1 RUBBER LINED yy❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING LINING OR ❑ 5 GLASS LINING 6 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES— NO X D.EXTERIOR 1 POLYETHYLENE WRAP ❑ 2 COATING 3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC CORROSION PROTECTION ❑ 5 CATHODIC PROTECTION 91 NONE 95 UNKNOWN 99 OTHER E.SPILL AND OVERFILL,BtC. SPILL CONTAINMENT INSTALLED(Y R) "� OVERFILL PREVENT! N EQUIPMFNT 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 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 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 A U BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A U 4 FIBEHGLASS PIPE CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL WI 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 MECRAN{CAL UNE LEAK X2 UNE TIGHTNESS 3 CONTINUOUS INTERSTmAL 4 ELECTRONIC LINE S AUTOMATIC PUMP 99 OTHER D. LEAK DETECTION ❑ (DETECTOR TEST NG ❑ MONITORING ❑ LEAK OETECTOR ❑ SHUTDOWN ❑ V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK 2 RECONCILIATIONMANUAL ORY ❑ 3 VADOZEMONITORING ❑ 4 AUTOMATGAUGING IC TANK ❑ 5 GROUND MONITORING TER 6 ANNUALTESTINGTANK O 7 CONTINUOUS MONITORING INTERSTITIAL ❑ 8 SIR ❑ 9 WEEKLY GAUGING TESTING❑ 10 TEOSTINGY TANK 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) 1.ESTIMATED DATE LAST USED(MOID YN 2.ESTIMATED QUANTITY OF _ 3.WAS TANK FILLED WITH YES ❑ NO 1 y SUBSTANCE REMAINING �C/ GALLONS INERT MATERIAL? THIS FORM HAS SEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, 1S TRUE AND CORRECT TANK OWNER'S NAME DATE (PRINTED 6 SIGNATURE) LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY# Q(J 40 3 7 TANK is a,;�, STATE I.D.# 3 f �� 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 INSTALLATIONS.THIS FORM SHOULD BE ACCOMPANIED BY A PLOT PLAN. FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS FORM B (6.95)