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• STATE OF CALIFORNIA .•°w;;;' 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 ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT6 TEMPORARY TANK CLOSURE D ❑ � 8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: �'f r• 1 P,w a �" G I. TANK DESCRIPTIONCOMPLETE ALL ITEMS- SPECIFY IF UNKNOWN 0. ONTIER'S TANK I.D.M Ct L B. MANUFACTURED BY: `q C. DATE INSTALLED(MOADAYNEAR) D. TANK CAPACITY IN GALLONS: IL TANK CONTENTS IF A-1 IS MARKED,COMPLETE ITEM C. VV CL A xl 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. ❑ 99 OTHER(DESCRIBE IN ITEM D.BELOW)C. to REGULAR UNLEADED ❑ 3 DIESEL ❑ 8 AVIATION GAS ❑ 2 PETROLEUM ❑ 80 EMPTY ❑ 1 PRODUCT ® 1D PREMIUM UNLEADED ❑ 4 GASAHOL ❑ 7 METHANOL [j :j3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 1c MIDGRADE UNLEADED El JETFUEL ❑ 8 M85 2 LEADED D. IF(0.1)IS NOT MARKED. ENTER NAME OF SUBSTANCE STORED C.0.S.k III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A B.AND C,AND ALL THAT APPLIES IN SOX D AND E A. TYPE OF ❑ i DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 5 INTERNAL BLADDER SYSTEM 95 UNKNOWNSYSTEM I� 2 SINGLE WALL ❑ 4 SINGLE WALL IN A VAULT ❑ 99 OTHER B. TANK 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP (PriR'YTMk) ❑ 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 UNING L� 6 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 100•% METHANOL? YES_ NO— D.EXTERIOR ❑ 1 POLYETHYLENE WRAP 2 COATING CORROSION [:] ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER E.SPILL AND OVERFILL,etc. SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) DROP TUBE YES_ NO STRIKER PLATE 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 U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION A 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 BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A U 4 FIBERGLASS PIPE CORROSION A 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL W/COATING A U B 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 IECHNsou UHE UTAH ❑2 MIE TwHlxEss ❑3 ca89Mwus wrERsnTIu A Eu cnwxlc uM; s AuroMAnc PUMP OE�ECfOR iE811Na WMI'mIH9 � LEMf OETECfOR O SHUT[IOwx ❑ 99 OTHER V.TANK LEAK DETECTION ❑ 7 CONTINUOUS NTERSTTAL ❑ 2 MANUAL ZE RECONCIUATONORY ❑ 3 MONITORING ❑ 4 AUTOMATGAUGING MONITORING TANK ❑ 5 GROUND MONTORING TER ❑ 6 ANNUAL TANK MONITORING ❑ 8 SIR 9 WEEKLY MANUAL ❑10 MONTHLY TANK ❑ 95 UNKNOWN ❑ 99 OTHER TANK GAUGING TESTINGHL VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE N.PLACE) 1.ESTIMATED DATE LAST SED(MO/DAY/YR) 2.ESTIMA QUANTITY OF 3.WAS TANK FILLED WITH ,/i,LL SUBST CE REMAINING ��J GALLONS INERT MATERIAL? YES ❑ NO-�/I� THIS FORM HAS BEEN COMPLETED UNDER PENA OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT YANK-oWMER'S10AM ,{ (PRIMEDa SIONAWRET�/.C, t,�h I.L^. �1ic�-_ L�(1✓J-'rLQ� oaTE�,��ii LOCAL AGENCY USE ONLY THE STATE I.D.NUM R IS COMPOSED OF THE FOUR NUMBERS BELOW G r STATE LD:# COUNTY# JURISDICTION# FACILITY# S 0 TANK# (,-)D FaY FTTJ 1 9 PERMIT NUMBER PERMIT APPROVED BYIDATE PERMIT EXPIRATION DATE THIS FORM MUST BE ACCOMPANIED OY A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. FORM C MUST BE COMPLETED FOR INSTALLATIONS. THIS FORM FORM B (695)SHOULD BE ACCOMPANIED BY A PLOT FLAW THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UwROUND STORAGE TANK REGULATIONS