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STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD , _ o UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B = e •��LI.QP HSP COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ON SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE I�T_8 TANK REMOVED ' DBA OR FACILITY NAME WHERE TANK IS INSTALLED: S, _s /z 7- 1 j_/ I. TANK DESCRIPTION COMPLETE ALL ITEMS— SPECIFY IF UNKNOWN A. OWNER'S TANK L D.M B. MANUFACTURED BY: C. DATE INSTALLED(MOIDAY/YEAR) D. TANK CAPACITY IN GALLONS: IL TANK CONTENTS IF A-1 IS MARKED,COMPLETE ITEM C- A I MOTOR VEHICLE FUEL ❑ 4 OIL B. C. ❑ 1a REGULAR UNLEADED ❑ 3 DIESEL ❑ 6 AVIATION GAS ❑ 2 PETROLEUM ❑ BO EMPTY i PRODUCT ❑ lb PREMIUM UNLEADED ❑ 4 GASAHOL ❑ 7 METHANOL ❑ lc MIDGRADE UNLEADED ❑ 5 JET FUEL ❑ 8 M85 ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE 2 LEADED ❑ 99 OTHER(DESCRIBE IN ITEM D.BELOW} D- IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S.4): 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 ❑ 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 lam' 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 IGD% METHANOL COMPATIBLE W/FRP (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER C.INTERIOR ❑ 1 RUBBER LINED 2 ALKYD LINING ❑ 3 EPDXY LINING 4 PHENOLIC LINING LINING OR ❑ 5 GLASS LINING 6 UNLINED L-1 95 UNKNOWN ❑ 99 OTHER COATING IS LINING MATERIAL COMPATIBLEJJI WTH 1001% METHANOL? YES— NOS\ 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,Or- SPILL CONTAINMENT INSTALLED R} OVERFILL PREVENTLCINrpQUIPMENT INSTALLED(YEAR) DROP TUBE YES NO STRIKERPLATE 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 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION A CUJ 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 1 BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A U 4 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL WICOATNG 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 D. LEAK DETECTION 1 MECHANICA LINE LEAK 2 LINE TIGHTNESS ❑3 CONTINUOUS INTERSTIT ALE:l 4 ELECTnNNPC LINE ®5 AIIi OMATIC PUMP 99 ETHER DETECTOR TESTING MONITORING LEAK DETECTOR SHUTDOWN V.TANK LEAK DETECTION ❑ 1 VISUAL CHEEK 2 RMANUAL ECONCILIATION MONITORING ❑ 3 MONITORING ❑ 4 AUTOMATGAUGINGIC TANK ❑5 GROUND TEESTINGTANK ❑ 7 MONITORING CONTINUOUS INTERSTITIAL ❑ 8 SIR ❑ 9 TANK GAUGING TESTING❑10 MONTHLY TANK ❑ 95 UNKNOWN 99 OTHER VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) 1.ESTIMATED DATE LAST USED IMOIDDAYNR) 2.ESTIMATED QUANTITY OF /Y 3.WAS TANK FILLED WITH YES ❑ NO �. SUBSTANCE REMAINING GALLONS INERT MATERIAL 7 t % I THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND Td THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT TANK OWNER'S NAME DATE (PRINTED d SIGNATURE) LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW l L1 .13 r COUNTY# JURISDICTION N FACILITY# DOZ/0 3TANK# CGI STATE 04 3115 PERMIT NUMBER PERMIT APPROVED BYIDATE 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 FORM B (6-95)SHOULD BE ACCOMPANIED PLOT PLAN. THIS FORM THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND S ATEG NS �� '7/-#'' +q V