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STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED ON 0% ONEITEM 2 INTERIM PERMIT F__] 4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE 8 TANK REMOVED 1 1 DBA OR FACILITY NAME WHERE TANK IS INSTALLED: I L9 _s Qjj, -1—A 1. TANK DESCRIPTION COMPLETE ALL ITEMS— SPECIFY IF UNKNOWN A. OWNER'S TANK 1.D.# B. MANUFACTURED BY: C. DATE INSTALLED(MOIDAYNEAR) D. TANK CAPACIF"Y IN GALLONS: 11.TANK CONTENTS IF A-1 IS MARKED,COMPLETE ITEM C. A. 1 MOTOR VEHICLE FUEL E�] 4 OIL B. C la REGULAR UNLEADED 3 DIESEL L_j 6 AVIATIONGAS ,)—< 0 80 EMPTY �<l PRODUCT lb PREMIUM UNLEADED 4 GASAHOL 7 METHANOL F_� 2 PETROLEUM lc MIDGRADE UNLEADED 5 JET FUEL 8 M85 Ej 3 CHEMICALPRODUCT E:j 95 UNKNOWN E::] 2 WAST �Kl LEADED 99 OTHER(DESCRIBE IN ITEM D.BELOW 0. IF(A.1)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 IN BOX D AND E A. TYPE OF E:ll 1 DOUBLE WALL F—] 3 SINGLE WALL WITH EXTERIOR LINER 5 INTERNAL BLADDER SYSTEM 0 95 UNKNOWN SYSTEM 2 SINGLE WALL F-1 4 SINGLE WALL IN A VAULT 99 OTHER B. TANK I BARE STEEL F_� 2 STAINLESS STEEL 3 FIBERGLASS 4 STEEL CLAD W1 FIBERGLASS REINFORCED PLASTIC MATERIAL E:] 5 CONCRETE r-1 6 POLYVINYL CHLORIDE 7 ALUMINUM E:j 8 100% METHANOL COMPATIBUEW/FRP (Pdmary Tank) 9 BRONZE 1:3 lo GALVANIZED STEEL E:] 95 UNKNOWN 99 OTHER C.INTERIOR F__] I RUBBER UNED 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—N D.EXTERIOR 1 POLYETHYLENE WRAP F_� 2 COATING 3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC CORROSION PROTECTION E] 5 CATHODIC PRoTEc-nON ><gl NONE 95 UNKNOWN 99 OTHER SPILL�UNI I AINIMENT INSTALLED WR) OVERFILL PREVENTI�&RPMENT INSTALL D(YEAR) No DISPENSER CONTAINMENT YES— NO E.SPILL AND OVERFILL,etc. DROP TUBE YES— NO STAIK R PLATE YES IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE ArQ)l SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION A01 SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND A k)l 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 STEELWICOATING A U 8 100% METHANOL COMPATIBUEW/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER— D. LEAK DETECTION LEAK [:]2'M'E'MWNI� 013�IJWS IIM� M 4 DEMONIC ME 0 5=PU' 99 OTHER 1 MECKWIM ME DEllmoll UiAK DMMR V.TANK LEAK DETECTION ;I NUALTANK W2 MANUAL INVENTO� MONITORING 1 VISUAL CHECK W 0 3 VADOZE ED 4 AUTOMATIC TANK GROUND WATER MW TAESTING RECONCILIATION MONITO ING GAUGING OTHER 7 CONTINUOUS INTERSTITIAL SIR E] 9 WEEKLY MANUAL E]10 MONTHLY TANK 95 UNKNOWN ';9�99 MONM TANK GAUGING TESTING VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) 1.ESTIMATED DATE LASTIED(M7 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES 0 N I I _ 4'jRl I SUBSTANCE REMAINING GALLONS INERT MATERIAL 7 THIS OpM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT TANK OWNERS NAME DATE (PRINTED&SIGNATURE LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY# TANK# C(p STATE I.D.# Uff I = FT:F-= PERMIT NUMBER I PERMIT APPROVED BY/DATE I PERMIT EXPIRATION DATE THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATI FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. FORML.MUST BE COMPLETED FOR INSTALLATIONS.THIS FORM FORM B (6-95)SHOULD BE ACC I I EDBY THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THEVROUND'(STORAGE TANK REGULATIONS 0 71 lqddjmp qIE