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• °es STATE OF CALIFORNIA - "� �'. STATE WATER RESOURCES CONTROL BOARD u d m e UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B > _ , I COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOS SIE V y ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT,A ❑ 6 TEMPORARY TANK CLOSURE ❑ B TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLE , �?Y1 E;fei ?17"3& I. TANK DESCRIPTION COMPLETEALLITEMS- SPECIFY IF UNKNOWN VV A OWNER'S TANK I.D. I '(, B. MANUFACTURED BY: C. DATE INSTALLED(MOIDAV/VEAR) I G' D. TANK CAPACITY IN GALLONS: ' ' ILTANK CONTENTS IFA-1 IS MARKED,COMPLETE ITEM C. A. t MOTOR VEHICLE FUEL ❑ 4 OIL B. C. 19 REGULAR UNLEADED ❑ 3 DIESEL ❑ 6 AVIATION GAS 80 EMPTY 1 PRODUCT ❑ 1b PREMIUM UNLEADED ❑ 4 GASAHOL ❑ 7 METHANOL ❑ 2 PETROLEUM ❑ ❑ 10 MIDGRADE UNLEADED ❑ 5 JET FUEL ❑ 8 M85 ❑ 3 CHEMICALPRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED ❑ 99 OTHER(DESCRIBE IN REM O.BELOW) D. IF(A1)IS NOT MARKED. ENTER NAME OF SUBSTANCE STORED C.A.S.#: III, TANK CONSTTRRIUCTION MARK ONE ITEM ONLY IN BOXES A S.AND C.AND ALL THAT APPLIES IN BOX D AND E A. TYPE OF vii 1 DOUBLE WALL F-13 SINGLE WALL WITH EXTERIOR LINER ❑ 5 INTERNAL BLADDER SYSTEM ❑ 95 UNKNOWN SYSTEM E❑55 2 SINGLE WALL ❑ 4 SINGLE WALL IN A VAULT ❑ 99 OTHER B. TANK Imo) 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP (PtIMary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER C.INTERIOR ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY UNING ❑ 4 PHENOLIC LINING LINING OR ❑ 5 GLASS LINING ar 8 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES— NO— D.EXTERIOR 0fr 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC CORROSION91 NONE 1-195 UNKNOWN ❑ 99 OTHER PROTECTION ❑ 5 CATHODIC PROTECTION ❑ E.SPILL AND OVERFILL,ESC. SPILLCONTAINMEN INSTALLED(YEAR) .I OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) DROP BE YES NO KER PLATE YES NO DISPENSER CONTAINMENT VES NO_ IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION A 6,1 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)A U 4 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL W/COATING A U 8 100% MET AND COMPATIBLE W/F PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN 99 OTHER1 IC.k.11?e. B�1 MEtlNMGL UNE LEAN 2 LINE TIOHINESE 3 CONi1NlIW5 WTPASTRNL- 4 ELEOMONIC UNE ❑5 AUTOMATIO POLI° ❑ 99 OTHER D. LEAK DETECTION nC' ❑ UK TIG � N - LFAN OETEcroN sNuroovM V.TANK LEAK DETECTION OZE �/�� ❑ 1 VISUAL CHECK ❑ 2 RECONCILIATIONORY ❑ 3 MONIITORING " 4 GAUG NGIC TANK ❑5 MONITORING TER ❑ 6 ANNUAL TANK NUOUS INTERSTITIAL ❑ B SIR ❑ 9 TANK GA GANGAL ❑ 10 MEST HLy TANK ❑ 95 UNKNOWN ❑99 OTHER :e ONITORING 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 7 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✓L11'LD DATE �,T (PRINTED 8SIGNATURE) C t' Mer 4 2* LOCAL AGENCY USE ONLY TITHE TSITATE I.D.N R OMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY# q TANK# STATE I.D.# m i A- (a a FfUols 101101E PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORMA HAS BEEN FILED. FORM C MUST BE COMPLETED FOR INSTALLATIONS. THIS FORM FORM B (6-95)SHOULD BE ACCOMPANIED BY A PLOT PLAN. FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS Lf�6�LJ