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STATE OF CALIFORNIA \/ STATE WATER RESOURCES CONTROL BOARD 3 d� m o UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B > _ , COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY 1 NEW PERMIT O 3 RENEWAL PERMIT O 5 CHANGE OF INFORMATION T PERMANENTLY CLOSED ON SITE ONE REM 2 INTERIM PERMIT O 4 AMENDED PERMIT E:] 6 TEMPORARY TANK CLOSURE O 8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: (Q(Jla - Ale C^4., Was h I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A OWNER'S TANK I.D.M B. MANUFACTURED BY: C. DATE INSTALLED(MO/DAYNEAR) D. TANK CAPACITY IN GALLONS: !Q �Da k/j/ys III TANK CONTENTS IF A-1 IS MARKED,COMPLETE ITEM C. p 5 1 MOTOR VEHICLE FUEL O 4 OIL B. O, to REGULAR UNLEADED 0 3 DIESEL O 6 AVIATION GAS O 2 PETROLEUM O 80 EMPTY 1 PRODUCT ib PREMIUM UNLEADED Q 4 GASAHOL ] METHANOL O 1C MIDGRADE UNLEADED O 5 JETFUEL ❑ 8 M85 Q 3 CHEMICALPRODUCT O 95 UNKNOWN 2 WASTE O 2 LEADED 99 OTHER(DESCRIBE IN ITEM D.BELO? D. IF(At)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 A. TYPE OF USI 1 DOUBLE WALL a 3 SINGLE WALL WITH EXTERIOR LINER O 5 INTERNAL BLADDER SYSTEM ❑ 95 UNKNOWN SYSTEM O 2 SINGLE WALL Q 4 SINGLE WALL IN A VAULT 0 99 OTHER B. TANK 1 BARE STEEL O 2 STAINLESS STEEL O 3 FIBERGLASS O 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL 5 CONCRETE O 6 POLYVINYL CHLORIDE O T ALUMINUM O 8 100% METHANOL COMPATIBLE W/FRP (Primary Tank) 9 BRONZE [D 10 GALVANIZED STEEL E] 95 UNKNOWN 0 99 OTHER C.INTERIOR ❑ 1 RUBBER LINED Q 2 ALKYD LINING O 3 EPDXY LINING O 4 PHENOLIC LINING LINING OR 5 GLASS LINING Q 6 UNLINED 95 UNKNOWN O 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 10094 METHANOL? YES— NO— D.EXTERIOR � 1 POLYETHYLENE WRAP O 2 COATING O 3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC CORROSION PROTECTION 5 CATHODIC PROTECTION O 91 NONE O95 UNKNOWN 0 99 OTHER E.SPILL AND OVERFILL,etc. SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) DROP TUBE YES_ NO_ STRIKER PLATE YES NO DISPENSERCONTAINMENT 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 99 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 T 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 DETECTION O 1 MECIUNCY LME LEAK 2 E TIGHTNESS 3 COrRINUWS IMERSTRW 4 ELECRIONIC NNE 5 AMCNATIC PUMP EETEGTOR I� LM TESTING LN)HTMING LEAK DETECTOR O EHLRD m 99 OTHER V.TANK LEAK DETECTION Q 1 VISUAL CHECK D 2 MANUAL RECONCILIATION MONITORING O 3 VADOZE MONIITORING O 4 TANK GAUGING AUTOMATIC TANK O S GROUND MONITORING O 6 ANNUALTESTING T INTRSTITIALQ 9 WEEKLY MANUAL O 10 MY TANK O 95 UNKNOWN 99 OTHER® N 6 SIR TANK GAUGINGTESTING 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 O NOE::] SUBSTANCE REMAINING GALLONS INERT MATERIAL 7 THIS FORM HAS BEEN COMPLETED UN2E5 PENALTY OF RJURY AND O HE BEST F MY K W EDGE,IS TRUE AND CORRECT TANK OWNER'S NAME d24DATE (PRINTED 6 SIGNATURE) LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY# TANK# STATE LD:# m PERMIT NUMBER 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 PI 71LE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE' ?GROUND STORAGE TANK REGULATIONS FORM B (6-95) N� 11