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STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION-FORM B I COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. •a' 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED N SITE 1 NEW PERMIT 3 RENEWAL PERMIT y� EMARKLY ❑ Oa AMENDED PERMIT O 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVEDM 2 INTERIM PERMIT sTa-no�► - I -a DBA OR FACILITY NAME WHERE TANK IS INSTALLED: I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFYIFUNKNOWN B. �MANUFACTURED BY:`S ` S A pWNER'S TANK I.D.f 2 C. DATE INSTALLED(MCIDAY/YEAR) D. TANK CAPACITY IN GALLONS; II.TANK CONTENTS IF A-1 IS MARKED,COMPLETE ITEM C. a REGULAR UNLEADED n` 3 DIESEL ❑ 6 AVIATION GAS C. A. ® I MOTOR VEHICLE FUEL ❑ 4 OIL B. ® 10 PREMIUM UNLEADED u 4 GASAHOL ❑ 7 METHANOL O 2 PETROLEUM O 60 EMPTY ® 1 PRODUCT ❑ 1c MIDGRADE UNLEADED O 5 JET FUEL ❑ 8 M85 ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED ❑ 89 OTHER(DESCRIBE IN REM D.B ELOW) C.A.S.M: D. IF(A-1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED 8Q0 Co(0L 1 III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A S.AND C,AND ALL THAT APPLIES IN BOX D AND E al I DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 5 INTERNAL BLADDER SYSTEM ❑ 95 UNKNOWN A. TYPE OF L SYSTEM ❑ 2 SINGLE WALL ❑ 6 SINGLE WALL IN A VAULT ❑ 99 OTHER O 1 BARE STEEL O 2 STAINLESS STEEL [R 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B. TANK O MATERIAL F-1 5 CONCRETE 8 POLYVINYL CHLORIDE ❑ 7 ALUMINUM E:] 8 100% METHANOL COMPATIBLE W/FRP (Primary Twk) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER C.INTERIOR ❑ I RUBBER LINED O 2 ALKYD LINING ❑ 3 EPDXY UNING ❑ 4 PHENOLIC LINING LINING OR ❑ 5 GLASS LINING 6 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER COATING IS UNING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_x NO— D.EXTERIOR ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ® 4 FIBERGLASS REINFORCED PLASTIC CORROSION gt NONE O 95 UNKNOWN ❑ 99 OTHER PROTECTION 715 CATHODIC PROTECTION EDSPILL CONTAINMENT 1 STALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) E.SPILL AND OVERFILL,etc. DROP TUBE YES NO_ STRIKER PLATE VES NO_ DISPENSER CONTAINMENT VES V NO IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND.BOTH IF APPLICABLE A. SYSTEM TYPE A U I SUCTION A 2 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION A U I SINGLE WALL A 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 POLYWNVL CHLORIDE(PVC)A DFIBERGLASS 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 A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION1 KCIWIG UNE LEAS 2 WE Tau MS 3 caNf WS NMRII L 4 BE=)NIC UNE s AuroMAnc waw ❑ of EmD6 ❑ ns'RWI YON qRq 6 a ��R SM=C ❑ 99 OTHER V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 ANUAL INVENTRECONCILATIONORY ❑ 3 MONIITORING ®VAOZE 4 GAUGNGIC TANK ❑ 5 MONITORINGROUNDWAG ❑6 ANNUAL TESTINGTANK ® 7 MONITORING INTERSTITIAL O B SIR ❑ 9 TAEEK NK GAUGINUAL O 10 TESTING TANK ❑ g5 UNKNOWN 99 OTHER 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 SUBSTANCE REMAINING GALLONS INERTMATERIAL? YES [:j NO❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT TANK OWNER'S NAME �A ^�L /e C� - p /,z9/9B (PRINTED 4NER'S NA) l/�A`Y-/U�//-/^' LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSE F E FOUR NUMBERS BELOW COUNTY f JURISDICTION# FACILITY TANK f O STATE I.D:# m -t 16 O PERMIT NUMBER PERMIT APPROVED BYIDATE PERMIT EXPIRATION DATE THIS FORM MUST BE ACCOMPANIED BY A PERMIT APLL TION.FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED 'M C MUST BE COMPLETED FOR INSTALLATIONS. THIS FORM SHOULD BE ACC MPANIE BY A PLOT'%wA FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING 7,0ADERGROUND STORAGE TANK REGULATIONS FORMS (6-95) /O 1L 61 q8 v \