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•Oti STATE OF CALIFORNIA �P STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B 1 - COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY F-11 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ON SITE ONE ITEM ❑ 2 INTERIM PERMIT 4 AMENDED PERMIT r ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED DBr A OR FACILITY NAME WHERE TANK IS INSTALLED: i P v�� i '--o I) / dij I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A. OWNER'S TANK I.D.Y B. MANUFACTURED BY: 4,- Com,— C. DATE INSTALLED(MOIDAYNEAR) 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 ❑ ib PREMIUM UNLEADED ❑ 4 GASAHOL ❑ 7 METHANOL ❑ 2 PETROLEUM E] //""BO EMPTY 1 PRODUCT ❑ 1c: MIDGRADE UNLEADED ❑ 5 JET FUEL ❑ 8 M65 ❑ 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.N: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A,B•AND C,AND ALLTHAT 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 Ell SINGLE WALL ❑ 4 SINGLE WALL IN A VAULT ❑ 99 OTHER B. TANK 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD WI FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W1FRP (Primary Tank) ❑ g BRONZE ED10 GALVANIZED STEEL Ll95 UNKNOWN ❑ 99 OTHER C.INTERIOR ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING LINING OR ❑ 5 GLASS LINING 'E91,6 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER COATING IS LINING MATERIAL COMPATIB E WITH 100% METHANOL? YES_ NO>�\ D.EXTERIOR ❑ 1 POLYETHYLENE WRAP F❑ 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC CORROSION 91 NONE ❑ 95 UNKNOWN E] 99 OTHER PROTECTION ❑ 5 CATHODIC PROTEcnON SPILL CONTAINMENT 1NSTALLE (Y R] OVERFILL PREVENTION QUIPMENT INSTALLED(YEAR) E.SPILL AND OVERFILL,eIC. DROP TUBE YES NO STRIKER PLATE YES NO DISPENSER CONTAINMENT ES NO 41 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 CUU)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)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 WI 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 MECHANICAL UNE LEAK [:]2 UNE TIGHTNESS ❑3 CONTINUOUS INTERSTITIAL [74 ELECTRDNIC LINE ❑5 AUTOMATIC PUMP P' gg OTMER 9 D. LEAK DETECTION 71 DETECTOR TESTING MONITORING LEAK DETECTOR SHUTDOWNS V,TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 MANUAL NOAY ❑ 3 MO a RING ❑ 4 AUTOMATGAUGING IC TANK ❑ 5 MONITORING UND TER ❑ 6 ANNUATESTING ❑ 7 CONTINUOUS INTERSTITIAL ❑ 8 SIR ❑ 9 WE LY MANUAL L]10 MONTHLY TANK 95 UNKNOWN -Z99 OTHER MONITORING K NTESTING Vl.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) F ESTIMATED DATE LAST USED(MO/DAYNR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES E] NO❑ SUBSTANCE 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 DATE (PRINTED h SIGNATURE) LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY# TArr��l STATE I.Dl ❑❑ 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 SHOULD BE ACCOMPANIED BY A PLOT PULE THIS FORM WITH�TlHE�LOCAL AGENCY IMPLEMENTING THE UGROUND STORAGE TANK REGULATIONS FORM B (6.95) r'.4.j t L- )' u J. � I E'. y d i L y T d .,