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I • • STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM B COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. o..,. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CL9911-Ousu ONE REM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE B TANK REMOVED ' O DBA OR FACILITY NAME WHERE TANK IS INSTALLED: I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A OWNER'S TANK 1.D.N na B. MANUFACTURED BY: unknown C. DATE INSTALLED(MOIDAY/YEAR) unknown D. TANK CAPACITY IN GALLONS: 1 , 000 al II.TANK CONTENTS IF A•1 IS MARKED,COMPLETE ITEM C. A [3�k1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C. ❑ 7a REGULAR UNLEADED 3 DIESEL ❑ 6 AVIATION GAS ❑ 2 PETROLEUM ❑ BO EMPTY 1 PRODUCT ❑ 10 PREMIUM UNLEADED H 4 GASAHOL ❑ 7 METHANOL ❑ It MIDGRADE UI&EADED 5 JET FUEL ❑ B M85 ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE 2 LEADED El 99 OTHER(DESCRIBE IN ITEM D.BELOM D. IF(A1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S.# III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.S.AND C.AND ALL THAT APPLIES IN BOX D AND A. TYPE OF F7 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 5 INTERNAL BLADDER SYSTEM ❑ 95 UNKNOWN SYSTEM M2 a 2 SINGLE WALL ❑ 4 SINGLE WALL IN A VAULT ❑ 99 OTHER B. TANK1 BARE STEEL ❑ 2 STAINLESS STEEL [:] 3 FIBERGLASS ❑ # STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ B 10094 METHANOL COMPATIBLE W/FRP (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER C.INTERIOR LJ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ A PHENOLIC LINING LINING OR ❑ 5 GLASS LINING X9 :] 6 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES— NO— D.EXTERIOR ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC CORROSION PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE X0 95 UNKNOWN E] 99 OTHER E.SPILL AND OVERFILL,etc. SPILL CONTAINMENT INSTALLED(YEAR) n OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) DROPTUBE YES_ NO_ STRIKERPLATE YES_ NO_ DISPENSER CONTAINMENT YES NO_ IV. PIPING INFORMATION CIRCLE A IFABOVEGROUNDOR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A X%1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U A FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION A 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 A FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL W/COATING A U 8 100% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION p 5 UNKNOWN A U 99 OTHER 0. LEAK DETECTION ❑1 MIUL ME LEAN 2 ONE M.MNESS 3 COUTIN"S WTEMTm A ELEMONK UNE 5 AU10MATIC PW DETECTOR' ❑ TESMG ❑ MON MNG ❑ LEAK MnCTM ❑ SHUTDOWN ❑99 OTHER V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 MANUAL RECONCILIATION MONITORING ❑ 3 MAONNIITORING ❑ A GAUGNGIC TANK ❑5 MONTORING TER ❑ TANK 6 TESTING IS❑ 7 MON TOR NG INTERSTITIAL ❑ 8 SIR ❑ 9 7ANEK GAUGINGAL ❑ 10 EBNTNGY TANK 95 UNKNOWN E:)99 OTHER VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PUCE) 1.ESTIMATED DATE LAST USED(MO/DAYIYR) 2.ESTIMATED QUANTITY OFO 0 3.WAS TANK FILLED WITH YES ❑ NO� unknown 1970 SUBSTANCE REMAINING GALLONS VERT MATERIAL? THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TOJVE BEST OF 4Y KNOWL DGE,IS TRUE AND CORRECT TANK OWNER'S NAME / — DATE (PRIL. MED 6 SIGNATURE) LOCAL AGENCY USE ONLY THE ATE I.D.NUMBER IS COMPOSED OFTHE FOUR NUMBERS LOW L COUNTY# JURISDICTION a FACILITY If TANK M STATE I.D:# m 6- Z PERMIT NUMBER PERMIT APPROVED BYIDATE PERMIT EXPIRATION DATE 0-1i00 �lj THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATI�RM A,UNLESS A CURRENT FORM A HAS BEEN FILED. FORM T BE COMPLETED FOR INSTALLATIONS. THIS FORM SHOULD BE ACCOMPANIED BY A PLOT PUN. IS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UND OUND STORAGE REGULATIONS TANK REGULS FORM 8 (6.95) a'J� � 7 �� C� �,(��