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1%w •I 's oncee STATE OF CAUFORNIA STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION -FORM B 1 COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. ❑ MARK ONLY F71 NEW PERMIT O 3 RENEWAL PERMIT � 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSEON SITIN ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT a 6 TEMPORARY TANK CLOSURE ❑ B TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: G HEv gc>r4 S-rAnoN I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN 17-5"4- Vl 8. MANUFACTURED BY: �yNi=-NS A OWNER'S TANK I.D.# 1 C. DATE INSTALLED(MOIDAY/YEAR) �- , D. TANK CAPACITY IN GALLONS: j2 C]Qd II.TANK CONTENTS IF A-1 IS MARKED.COMPLETE ITEM C. ® 1 MOTOR VEHICLE FUEL ❑ d OIL B. C. 1e REGUTAA UNLEADED ❑ 3 DIESEL ❑ 6 AVIATION GAS A. Q 1b PREMIUM UNLEADED 04 GASAHOL ❑ 7 METHANOL ❑ 2 PETROLEUM ❑ 80 EMPTY ® 1 PRODUCT ❑ 10 MKK;RADE UNLEADED a 5 JET FUEL ❑ 8 M85 ❑ 3 CHEMICALPRODUCT O 95 UNKNOWN Q 2 W�TE ❑ 2 LEADED ❑ 99 OTHER(DESCRIBE WITEM O.BELOW) D. IF(A1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S.#: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A B.AND C.AND ALL THAT APPLIES IN BOX D AND E ® El DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR UNER 5 INTERNAL BLADDER A. TYPE OF SYSTEM F] 95 UNKNOWN SYSTEM ❑ 2 SINGLE WALL ❑ d SINGLE WALL IN A VAULT ❑ 99 OTHER F-1I BARE STEEL ❑ 2 STAINLESS STEEL Is 3 FIBERGLASS O 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B. TANK MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ B 10096 METHANOL COMPATIBLE WIFRP (Primary Tank) ❑ 9 BRONZE O 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER C.INTERIOR ❑ I RUBBER UNED ❑ 2 ALKYD LINING ❑ 3 EPDXY UNING ❑ 4 PHENOLIC LINING LINING OR ❑ 5 GLASS LINING ® 6 UNLINED O 95 UNKNOWN ❑ 99 OTHER COATING IS UNING MATERIAL COMPATIBLE WITH 100% METHANOL? YES X NO— D.EXTERIOR ❑ 1 POLYETHYLENE WRAP O 2 COATING ❑ 3 VINYL WRAP ® d FIBERGLASS REINFORCED PLASTIC CORROSION91 NONE 95 UNKNOWN 99 OTHER PROTECTION r7s cATHoolc PROTECTION E:] SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) E.SPILL AND OVERFILL,BIC. DROPTUBE YES X 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 2 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL A U 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)PQ4 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U a CONCRETE A U 7 STEEL W/COATING A U B 100% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHOOICPROTECTICN A U 95 UNKNOWN A U 99 OTHER - D. YECN4NICIL LINE 1F.11L 2 INE TGNTNESS 3(XWM 1WS NTE0.9TnLLL d ELECTRONIC UNE 5 WOMLnC M)MR ❑ 99 OTHER D. LEAK DETECTION ❑ X09 ❑ MrING ® MONTau6D 'PI ILIA rLErcT. sNuloowN V.TANK LEAK DETECTION VAE /a ❑ ANNUAL 1 VISUAL CHECK ❑ 2 RMANUALECONCILIATIONORY ❑ 3 MONITORING '^� 4 GAUGING TIC TANK ED 5 MON TORINGGROUND WATER ❑ 6 TESTINGTANK f4'1 7 CONRNUOUSINTERSTITIAL ❑ 8 SIR El9 WEEKLY MANUAL ❑10 MONTHLY TANK ❑ 95 UNKNOWN ❑99 OTHER MONITORING TANKGAUGING TESTING VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) 1.ESTIMATED DATE LAST USED(MO/DAY/YR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES ❑ NO❑ SUBSTANCE REMAINING GALLONS INERT MATERIAL? THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT OD W. (PPINTED461GNATURE) LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOS"F THE FOUR NUMBERS B LOW COUNTY# JURISDICTION# FACILITY# TANK# STATE I.D.# / lid 6 O 6 PERMIT NUMBER PERMIT APPROVED SY/DATE PERMIT EXPIRATION DATE THIS FORM MUST BE ACCOMPANIED BY A PERMIT API TION-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILEC 'M C MUST BE COMPLETED FOR INSTALLATIONS. THIS FORM SHOULD BE ACCOMPANIED BAY FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING T,..*NDERGROUND STORAGE TANK REGULATIONS FORM B (6-95) jo//:6/f8 ` { L n n