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• STATE OF CALIFORNIA • "`.o"��` STATE WATER RESOURCES CONTROL BOARD o 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 CLOSED ON SITE ONE TEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: ( 4Un;y-, SS- - ` - I-S 2- 1. I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A OWNERS TANK I.D.k l B. MANUFACTURED BY: C. DATE INSTALLED(MOIDAYNEAR) I l I S D. TANK CAPACITY IN GALLONS: DOO II.TANK CONTENTS IF A-1 IS MARKED,COMPLETE ITEM C. A, t�d I MOTOR VEHICLE FUEL ❑ 4 OIL B. C, ie EGUW:UNLEADED ❑ 3 DIESEL ❑ 6 AVIATION GAS ❑ 2 PETROLEUM E] 80 EMPTY � 1 PRODUCT L^ 1b PRREMIUM UNLEADED ❑ 4 GASAHOL ❑ 7 METHANOL ❑ 1c MIDGRADE UNLEADED 5 JET FUEL ❑ 8 M85 ❑ 3 CHEMICALPRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED 99 OTHER(DESCRIBE IN ITEMD.BELOM D. IF(A.1)IS NOT MARKED. ENTER NAME OF SUBSTANCE STORED C.A S 8: 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 z 1 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 ❑ 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 (Primary Twk) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER C.INTERIOR ❑ I RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING LINING OR ❑ 5 GLASS LINING �6 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES— NO— D.EXTERIOR ❑ 1 POLYETHYLENE 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,MC. SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(NEAR) DROP TUBE YES_ NOJG STRIKER PLATE YES}� NO DISPENSER CONTAINMEN 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 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 4 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL W/COATING A 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 ❑1 MEpU UNE UE UW❑2 UNE MI[TKW 9 CCNIINUWS INTEPSRRAL 4 EU:CIRWIC LIEF 5 AUTOIMmC PUMP ❑ B9 OTTER oET aw r3mNo MC wm9 9E =R SHV1G01YH V.TANK LEAK DETECTION ❑ i VISUAL CHECK 2 MANUAL RECONCILIATION MONITORING ❑ 3 MONITORING ZE 4 GAUGING AUTOMATIC TANK ❑5 GROUND MONITORINGTER F7 ANNUALTANK 6 TESTING 7 MONITORING CONTINUOUSINTERSTITIAL ❑ 8 SIR ❑ 9 WEEK LY MANUAL ❑10 MONTHLYTESTING TANK ❑ 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PUCE) 1.ESTIMATED DATE LAST USED(MO/DAY/YR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YESNO SUBSTANCE REMAINING GALLONS INERT MATERIAL? ❑ ❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO BEST OF MY KNOWLEDGE,IS TRE D CORRECT TANK-OWRER7NAME DATE (PRINTED 851GNANRE) Q. LOCAL AGENCY USE ONLY THE STATE LD BER IS COMPOSED OF THE FOUR NUMBERS BELOW COUN N JURISDICTION It FACILITY M TANK N STATE I.D.# m PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLON-FORM A,UNLESS A CURRENT FORMA HAS BEEN FILED. FORM C MUST BE COMPLETED FOR INSTALLATIONS. THIS FORM SHOULD BE ACCOMPANIED BY A PLOT POFILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THWRGROUND STORAGE TANK REGULATIONS FORM 11 (6-95)