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STATE OF CALIFORNIA 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 O 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION Q 7 PERMANENTLY CLOSED ITE ONE REM 2 INTERIM PERMIT O 4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE O 8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: 740 7 E fPpj� /J I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN l� A OWNER'S TANK I.D.a B. MANUFACTURED BV: V C. DATE INSTALLED(MO/DAY/YEAR) D. TANK CAPACITY IN GALLONS: 0) II,TANK CONTENTS IF A-1 IS MARKED,COMPLETE ITEM C. S/ A, 12f 1 MOTOR VEHICLE FUEL a 4 OIL B. ry/, C. 1 REGULAR UNlEADB] 3 DIESEL a 6 AVIATION GAS / O 2 PETROLEUM O 80 EMPTY I �I ' PRODUCT � PREMIUM UNLEADm 4 GASAHOL Q 7 METHANOL 9AI is MIDGRADE UNLEADED 5 JETFUEL O B M85 P 3 CHEMICAL PRODUCT O BS UNKNOWN 2 WASTE O 2 LEADED 98 OTItEP(DESCRIBE IN REM D.BELOW) D. IF(A1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A S.f: I Y III. TANK CONSTRUPION MARK ONE ITEM ONLY IN BOXES A,B.AND C,AND ALL THAT APPLIES IN BOX D AND E It A. TYPE OF 1 DOUBLE WALL F-� 3 SINGLE WALL WITH EXTERIOR UNER a 5 INTERNAL BLADDER SYSTEM O 95 UN04OWN SYSTEM [1 2 SINGLE WALL O 4 SINGLE WALL IN A VAULT Q 99 OTHER B. TANK O 1 BARE STEEL O 2 STAINLESS STEEL O 3 FIBERGLASS Q 4 STEEL CUD W/FIBERGLASS REINFORCED PLASTIC MATERIAL O 5 CONCRETE O 6 POLYVINYL CHLORIDE F-1 7 ALUMINUM a 8 100% METHANOL COMPATIBLE W/FRP (PNmary T014 O 9 BRONZE O 10 GALVANIZED STEEL 95 UNKNOWN 99 OTHER C.INTERIOR 1 RUBBER LINED 2 ALKYD LINING 3 EPDXY LINING O 4 PHENOLIC LINING LINING OR O 5 GLASS LINING 8 UNLINED O 95UNKNOWN E] 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH IDD% METHANOL? YESL// NO— D.EXTERIOR 1 POLYETHYLENE WRAP O 2 COATING F-1 3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC CORROSION PROTECTION 5 CATHODIC PROTECTION Q 9/ NONE Q95 UNKNOWN O 99 OTHER E SPILL AND OVERFILL,BK:. 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 U 1 SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 98 OTHER C. MATERIAL AND A U 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 STEEL W/COATING A U 8 100% METHANOL COMPATIBLE WIFRP PROTECTION A U 9 GALVANIZED STEEL A U /0 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION Q 1 MECR.NIrAL ME UR O 2 UxE iE3TITIGN m O 3 caNRNuoca NITRsmw O 4 ELEMm UNE O 5 A nc mwEj 99 DINER pEiECfOR HG MONTORaq Um OEI cC SINIWNH V.TANK LEAK DETECTION O 1 VISUAL CHECK O 2 RECO CILIATIONORY O 3 MONITORING 0 4 AUTOMN GAUG MGIC TANK O S MON TORINGOUND WATER O 6 TESTINGANNUAL 7 MON TOR U INTERSTITIAL O 8 SIR ❑ 9 TANKLY MANUAL 0 10 MOGING NTHLY TANK O 95 UNKNOWN a 99 OTHER VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PUCE) 1.ESTIMATED DATE LAST USED(MO/DAY/YR) 2.ESTIMATEDQUANTITY OF 3.WAS TANK FILLED WITH YES NO SUBSTANCE REMAINING GALLONS INERT MATERIAL7 a O 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 G (PRINTED 491GNATURE) z / LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY A JURISDICTION x FACILITY M 7`j/3 TANK♦tel 1 FPrRIIT-lUlSeTR' TE I.D.# m PERMIT APPROVED BY/DATE 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 PLAN. RLE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS FORM B (6-95)