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STATE CF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD 4+ 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 CL ONE ITEM ❑ 2 INTERIM PERMIT ❑ d AMENDED PERMIT ❑ 8 TEMPORARY TANK CLOSURE Ey 8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: IP Y TU P Lu GL I I. TANK DESCRIPTION COMP92 LETE ALL ITEMS– SPECIFY IF UNKNOWN A OWNERS TANK I.D.r u B. MANUFACTURED BV: Gl C. DATE INSTALLED(MOA)AV/YEAR) pI D. TANK CAPACITY IN GALLONS f U I U K) G$ II.TANK CONTENTS IF A-1 IS MARKED,COMPLETE ITEM C. A M I MOTOR VEHICLE FUEL ❑ d OIL B. C. 1a REGULAR UNLEADED O 3 DIESEL ❑ 8 AVIATIONGAS ❑ 2 PETROLEUM ❑ SO EMPTY ❑ 1 PRODUCT ❑ ib PREMIUM UM.EADED ❑ d GASAHOL ❑ 7 METHANOL ❑ 3 CHEMICALPRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ Ic MIDGRPDE UNLEADED 5 JET FUEL ❑ 8 M85 ❑ 2 LEADED 9g OTHER(pESCRIBEMREM D.BELplST D. IF(A.1)IS NOT MARKED. ENTER NAME OF SUBSTANCE STORED C.a.s.r: 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 I DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 5 INTERNAL BLADDER SYSTEM ❑ 95 UNKNOWN SYSTEM 2 SINGLE-WALL ❑ d SINGLE WALL IN A VAULT ❑ 99 OTHER B. TANK L'J / BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ d STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 8 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% 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 ❑ 8 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO— D.EXTERIOR 1 POLYETHYLENE WRAP I�I 2 COATING CORROSION [:] 4--J ❑ 3 VINYL WRAP E] 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION rLXJt 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER E.SPILL AND OVERFILL,etc. SPILL CONTAINMENT INSTALLED(YEAR) OVERRLL PREVENTION EQUIPMENT INSTALLED(YEAR) DROP TUBE VES_ NO_ STRIKER PLATE YES_ NO__ DISPENSER CONTAINMENT YES_ NO— IV. O_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 d FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION A(U/I SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND AU I BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A U d FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 8 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 A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION ❑1 �cCIIAu IME LFAN 2 uxe Tloxrxess 3 cartMwus Ime951mu ❑ [LEcmavK uNL ❑5 Aurownc vUly 9EIECTOr1' T9SiING YOrAtORNO �.V(OEl c u 9Nm0Wc ❑ 99 OTHER V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 RC MANUAL IN ENTORY L] 3 VADOMONITORING ❑ 4 GAG WG C TANK ❑5 MON T GROUND WATER E]8 ANNUAGTANK 7 MON TORWG NUOUSINTERSTITIAL ❑ B SIR ❑ 9 WEEKLY MNG ANUAL ❑ 10 MONTHLY TANK ❑ g5 UNKNOWN ❑99 OTHER TANK AI TESTING VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PUCE) 1.ESTIMATEQ QATE USED(MO/DAY/YR) 2.ESTIMATED OUANTITY OF 3.WAS TANK FILLED WITH VVI SUBSTANCE REMAINING GALLONS INERT MATERIAL? YES ❑ NO� THIS FORM HAS BEEN COMPLETED UNDER PENALTY F PE JURY,AND TO THE BEST OF MY KNOWLEDGE, IST E AND CORRECT RG N TANK ERG AME �11I / (PRINTEDl81N ) DATE?� 7I LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW (/ STATE I.D:# COUNTY k JURISDICTION r FACILITY � TA ML7 19171,L PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE THIS FORM MUST BE ACCOMPANIED BY PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. FORM C MUST BE COMPLETED FOR INSTALLATIONS. THIS FORM FORMS (696) SHOULD BE ACCOMPANIED BY A PLOT PLALE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UJOGROUND STORAGE TANK EGULATIONS � .