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STATE OF CALIFORNIA ibw,�r 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 Y,• ONE ITEM ❑ 2 INTERIM PERMIT ❑ ❑ 5 CHANGE OF INFORMATION 7 PERMANENTLY CLO AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE Ez S TANK REMOVED �J lk DBA OR FACILITY NAME WHERE TANK IS INSTALLED: Y 7 u � 1 Y' I. TANK DESCRIPTION COMPLETE ALL ITEMS— SPECIFY IF UNKNOWN 0. OWNER'S TANK 1.D.a N B. MANUFACTURED BY; C. DATE INSTALLED(MO'DAY/YEAR) D. TANK CAPACITY IN GALLONS: I II.TANK CONTENTS IFA-1 IS MARKED,COMPLETE ITEM C. EIFF(Al) MOTOR VEHICLE FUEL ❑ 4 OIL 8 C I❑� 18 REGULAR UNLEADED O 3 DIESEL ❑ 6 AVIATION GAS PETROLEUM ❑ 9p EMpry ❑ 1C PREMIUM UNLEADED ❑ 4 GASAHOL ❑ 7 METFIANOL CHEMICAL PRODUCT ❑ UNNOWN LJ1c MIDGRADE UNLEADED ❑ 5 JET FUEL ❑ 8 M85 2 LEADED ❑ 99 OTHER(DESCRIBE N ITEM D.eELOWj S NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S.k: 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 L,J 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER SYSTEM ILJ�f 2 SINGLE WALL ❑ 5 INTERNAL BLADDER SYSTEM ❑ 95 UNKNOWN ❑ 4 SINGLE WALL IN A VAULT ❑ 99 OTHER B. TANK ,YJ i BARE STEEL ❑ 2 STAINLESS STEEL MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100%E METHANL CLAD OL ICOMPAATIBLE W RP RFJNrORBERGLASS CED PLASTIC (PrimaIy 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 COATING ❑ 95 UNKNOWN ❑ 99 OTHER IS LINING MATERIAL COMPATIBLE WITH IOD% METHANOL? YES_ NO— D.EXTERIOR ❑ 1 POLYETHYLENE WRAP2 CORROSION COATING ❑ 3 VINYL WRAP E34 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION 91 NONE ❑95 UNKNOWN ❑ 99 OTHER E.SPILL AND OVERFILL,SIC. SPILL CONTAINMENT INSTALLED(YEAH) OVERFlLL PREVENTION EQUIPMENT INSTALLED(YEAR--- TUBE YES__ NO_ $TgIKER PLATE VES_ 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 98 OTHER B. CONSTRUCTION SINGLE WALL A U 2 ICUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND A 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 STEELW/COATING A U PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION 8 100% METHANOL COMPATIBLE WiFRP A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION ❑1 � �UNE AF.N( ❑2 lWE IAWmE56 ❑3 CONTNU0115 NIERSIIIML O 4 MI;I;KImc UHE ❑5 A,,1 MW OETECfOA IESIPq AKINfORIKKV Q,Vt OEn:CTOR 91O_m V.TANK LEAK DETECTION ❑ as O HER ❑ 1 VISUAL CHECK ❑ 2 MANUAL INVENTORY ❑ 3 VADOZE ❑ 4 AUTOMATIC TANK 5 GROUND WATER ❑6 ANNUAL TANK ❑ 7 CONTINUOUS INTERSTITIAL RECONCILIATION MONITORING GAUGING ❑ MONITORING TESTING MONITORING ❑ 8 SIR ❑ 8 WEEKLY MANUAL ❑10 MONTHLY TANK ❑ 95 UNKNOWN ❑99 OTHER TANK AUGING TESTING VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) 1.ESTIMATED DATE LAST "kDAYNR) 2.ESTIMATED QUANTITY OF ��ll SUBSTANCEREMAINING 3.WAS TANK FILLEDWITHTH YES ❑ NO GALLONS INERT MATERIAL? THIS FORM.NEN COMPLETED UNDER PENAL F ER URY,AND T THE BEST F MY KNOW DGE,IS TRUE_ D C RRECT TANK OWNER'S NAME (PRINTED4916NAN8E) (�(� �. ) /1. i. /�r DAI2 2I LOCAL AGENCY USE ONLY THE STATE LD.NUMBER IS COMPOSED OFTHE FOUR NUMBERS BELOW C CO�a JURISDICTION M FACILITY a TANK M STATE I.D:# :: [PER:MITTMBER 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 PLA/AAINI E THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE U'' (GROUND STORAGE TANK REGULATIONS FORM B (6-95) I'