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STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B <n I COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOS Q ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT L❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED <1� DBA OR FACILITY NAME WHERE TANK IS INSTALLED: '0��-� Ge, 7 v�'�/�' /*7--47 1/13�y I. TANK DESCRIPTION COMPLETE ALL ITEMS— SPECIFY IF UNKNOWN 11 A OWNER'S TANK I.D.N /�/ L S. MANUFACTURED BY: C DATE 'NSTALLED(MO/DAV/YEAR) i/GJNOJ�O�, �. D. TANK CAPACITY IN GALLONS: �i LJ Chi Ii.TANK CONTENTS IF A-1 IS MARKED,COMPLETE ITEM C. 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. O, 1a REGULAR UNLEADED ❑ 3 DIESEL ❑ 6 AVIATION GAS A. — PRODUCT 1b PREMIUM UNLEADED ❑ 4 GASAHOL ❑ 7 METHANOL 2 PETROLEUM E] BO EMPTY ❑ Ic MIDGRADE UNLEADED E:] 5 JET FUEL ❑ 8 M86 ❑ 3 CHEMICALPRODUCT E:] 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED ❑ 99 OTHER(DESCRIBE IN TEMD.BELOW)) D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S.#: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.8,AND C.AND ALL THAT APPLIES IN BOX D AND A. TYPE OF I DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 5 INTERNAL BLADDER SYSTEM ❑ 95 UNKNOWN SYSTEM ❑ 2 SINGLE WALL ❑ 4 SINGLE WALL IN A VAULT ❑ 99 OTHER B. TANK ❑ I BARE STEEL ❑ 2 STAINLESS STEEL 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE 7 ALUMINUM ❑ 6 100% METHANOL COMPATIBLE W/FRP (PTIMaLY Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER C.INTERIOR ❑ 1 RUBBER UNED ❑ 2 ALKYD LINING ❑ 3 EPDXY UNING ❑ 4 PHENOLIC LINING LINING OR ❑ 5 GLASS LINING � UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO— D.EXTERIOR ❑ 1 POLYETHYLENE WRAP ❑ 2 COATNG ❑ 3 VINYL WRAP L—I 4 FIBERGLASS REINFORCED PLASTIC CORROSION 91 NONE 95 UNKNOWN 99 OTHER PROTECTION ❑ 5 CATHODIC PROTECTION ❑ ❑ SPILLCONTAINMENTINSTALLEO(YEAR) OVERFILL PREVENTION EDU IPM ENT INSTALLED(YEAR) E.SPILL AND OVERFILL,6T0. DROPTUBE 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 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL UBLE WALL A U 3 UNED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND A U I BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A IBERGLASS 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 - I MECHAMM UNEIF.AI! 2 ONE TIKMS 3 COMINUOUS IN(SRSiRIAL ❑4 ELECTRONIC LINE ❑5 AUTOMABC PUNP ❑ 99 OTHER D. LEAK DETECTION ❑ �TEc ❑ TE3nNG ❑ MOMIm m lFAK DETECTOR s99ToowN V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 RMANUAL ECONCILIATION MONITORING E] 3 VADOZE MONIITORING El AUTOMATGAUGING MONITORING TANK ❑ 5 GROUND MONTORINGTER ❑6 TESTINGTANK ❑ 7 CONMON INUOU INTERSTITIAL ❑ 8 SIR ❑ 9 WEETANKLY GINUAL ❑10 MOTHL TANK ❑ 95 UNKNOWN ❑ 99 OTHER ORIN VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PUCE) 1.ESTIMATED DATE LAST USED(MO/DAYNR) 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 TANK OWNER'S NAME DATE (PRINTED&SIGNATURE) LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNT`r# JURISDICTION# FACILITY# TANK#�� r�- STATE LD:# M7 d D 8 0 4 9 PERMIT NUMBER PERMIT APPROVED BYIDATE PERMIT EXPIRATION DATE 1 THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLN-FORMA,UNLESS A CURRENT FORM A HAS BEEN FILED. F STBE COMPLETED F STALLATI NS.THIS FORM SHOULD BE ACCOMPANIED BY A PLOT FWLE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING TH GROUND STORAGE TANK REGULATIONS FORM B (6.95)