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• STATE OF CAUFORNIA • •<• ""e STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM B COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. `�t,�G1,M,• • MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ON SITE ONE REM ❑ 2 INTERIM PERMIT a 4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: 'c6y-� 5 A— 0f I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A OWNER'S TANK I.D.• 3 B. MANUFACTURED BY: C. DATE INSTALLED(MO/DAYNEAR) D. TANK CAPACITY IN GALLONS: II.TANK CONTENTS IF A-1 IS MARKED,COMPLETE ITEM C. A. 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C 1e REGULAR UNLEADED a 3 DIESEL ED6 AVIATION GAS ❑ 2 PETROLEUM [:] 80 EMPTY 1 PRODUCT ❑ 1b PREMIUM UNLEADED ❑ 4 GASAHOL ❑ 7 METHANOL ❑ 1C MIDGRADE UNLEADED 06 JET FUEL � 8 M85 ❑ 3 CHEMICALPRODUCT 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED ❑ 99 OTHER IDESCRIBE IN ITEM D.BELOM 0. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A S.N 111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A,B.AND C.AND ALL THAT APPLIES IN BOX D AND E A. TYPE OF 1 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 ❑ 1 BARE STEEL ❑ 2 STAINLESS STEEL Y3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM 8 100% METHANOL COMPATIBLE W/FRP (PHm9ry Twk) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ W OTHER C.INTERIOR ❑ I RUBBER UNED 71 2 ALKYD LINING 3 EPDXY LINING 4 PHENOLIC UNING LINING OR ❑ 5 GLASS LINING t9 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 �c PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE 0 9 UNKNOWN ❑ 99 OTHER E.SPILL AND OVERFILL,B1F SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL P_WENTION EQUIPMENT INSTALLED(YEAR) DROP TUBE YES_ NO 1G STRIKER PLATE YES_ NO_ DISPENSER CONTAINMENT YES L NO IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION 2 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLEPIPING A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL 2 DOUBLE WALL A U 3 UNED 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) 4 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL W/COATING 2f 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 t MEcxuam LINE IFAI{ ❑2 LINE no3 W 3=Nua NTERST 4 ELEcmoaC LINE 5 urtownc mo ❑ 5e OTHER OE1ECi0R IESTIN9 MONRIXVIN, EFAN OETECiOR 9Uf00WN V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK 2 RECONCILIATIONMANUAL INVENTORY E] 3 MAOONOTORING 4 GAUGINGAUTOMATIMONITORING TANK ❑5 GROUND MON TORINGTER F-18 ANNUALTESTING 7 MON INUOU INTERSTTAL ❑ 8 SIR ❑ 9 WE KLY MANUAL F]10 TESTING Y TANK ❑ 95 UNKNOWN c:] 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 YES ❑ NO ❑ SUBSTANCE REMAINING GALLONS INERT MATERIAL? THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE PEST OF MY KNOWLEDGE, IS TRUE AN CORRECT n w,y zANK33INNGRS NAME DATE (PRINTM&SNUNRE) {_Ltnti. GL$ 0 LOCAL AGENCY USE ONLY THE STATE I.D R IS COMPOSED OF THE FOUR NUMBERS BELOW COUN JURISDICTION# FACILITY# TANK# STATE I.Dl m PERMIT NUMBER PERMIT APPROVED BY/DATE —7 ERM1T EXPIRATION DATE THIS FORM MUST BE ACCOMPANIED BY A PERMIT APP ONFORM A,UNLESS A CURRENT FORMA HAS BEEN FILED. FORM C MUST BE COMPLETED FOR INSTALLATIONS.THIS FORM SHOULD BE ACCOMPANIED BY A PLOT L LE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING TH RGROUND STORAGE TANK REGULATIONS FORM B (6-95)