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0 0 'Asow=e� 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 ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY ct Ogg ON SME ONE REM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6ppTEMPORA RY TANK CLOSURE ❑ 8 TANK REMOVE lhl I. TANK DESCRIPTION COMPLETE ALL ITEMS— SPECIFY' r� DBA OR FACILITY NAME WHERE TANK IS INSTALLED: nV V�SI F UNKNOWN A OWNER'S TANK I.D.# Z/�"I 4 C/G' n B. MANUFACTURED BY:_T, , (}, I I I^ rA'r C. DATE INSTALLED(MO/CAYNEAR) 'l- 5 I D. TANK CAPACITY IN GALLONS: 10,000 0 II.TANK CONTENTS IF A-1 IS MARKED.COMPLETE ITEM C. a A ❑ 2 MOPETROLEUM VEHICLE FUEL O BO OIL B �I 7 PRODUCT C ❑ 1a REGULAR UNLEADED ❑ 3 DIESEL ❑ 6 AVIATIONGAS Ib PREMIUM UNLEADED ❑ 4 GASAHOL ❑ 7 METHANOL 1c MIDGRADE UNLEADED ❑ 5 JET FUEL ❑ 8 M85 ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED ❑ 99 OTHER(DESCRIBE N ITEM D.BELON9 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.B,AND C,AND ALL THAT APPLIES IN BOX D AND E A. TYPE OF i DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR UNER ❑ 5 INTERNAL BLADDER SYSTEM ❑ 95 UNKNOWN SYSTEM 2 SINGLE WALL ❑ 4 SINGLE WALL IN A VAULT ❑ 99 OTHER B. TANK -)- STEEL F-12 STAINLESS STEEL ❑ 3 FIBERGLASS E::) 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP (Primary Tank) 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER C.INTERIOR ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING LINING OR ❑ 5 GLASS LINING a 8 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL YES- NO- D.EXTERIOR `U jnjr&YETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC CORROSION PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER E.SPILL AND OVERFILL,BLD. SPILL CONTAINMENT IBISTALLED(YEAR) OVERFI REVENTION EQUIPMENT INSTALLED(YEAR)- DROP TUBE YES NO STRIKER PLATE YES NO PE DES 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 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% METHANOL COMPATIBLE WIFRP, PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN q U OTHER rlekVe. Y!O#1- IIC. D. LEAK DETECTION 1 MECHONICAL LR1E LEAK O 2 UNE TKIMNESS 3 CONMKIWS IMERSI L ❑4 EUMMIC UNE Ej 5 AM WTIC nW 99 OTHER pE1ECTOA TES W MONITORING LEAK DETECTOR SHUTDOWN V.TANK LEAK DETECTION (❑ i VISUAL CHECK ❑ 2 MANUAL RECONCILIATIONOflY ❑ 3 MONANNUALTANK IITORIN6T OZE 4 GAUGING AUTOMATIC TANK ❑ 5 MONITORINGGROUND ❑ 6 TESTING 7 CON nNUOU INTERSTITIAL E] 8 SIR ❑ 9 WEETANKLY MANUAL ❑ 10 MOTESTINGHLY TANK ❑ 95 UNKNOWN ❑ 99 OTHER MITORVI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) 1.ESTIMATED DATE LAST USED(MO/DAYNR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH SUBSTANCE REMAINING GALLONS INERT MATERIAL YES ❑ 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 1-.4YTI ht7 DATE (PRINTED b SIGNATURE( U 04M LOCAL AGENCY USE ONLY THE STATE I.D. UM IS C MPOSED OF THE FOUR NUMBERS BELOW G COUNTY# JURISDICTION# FACILITY# TANK# STATE I.D.# m 0 IM1011011 PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE 0 1P mqt 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, FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS //Q(((''''l16, �//, FORME (fi-95) lY /