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STATE OFCAUFORNIA �� STATE WATER RESOURCES CONTROL BOARD u~,P� � UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM B 1 COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ONSTE ONE REM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: % ;'JIC ��✓7Gr SFS/✓iC �� I I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A OWNER'S TANK I.D.Y /y ��qq B. MANUFACTURED BY: NQ C. DATE INSTALLED(MO/DAYNEAR) (�'/t/)C/U( D. TANK CAPACITY IN GALLONS: 't�r©p II,TANK CONTENTS IF A-1 IS MARKED,COMPLETE ITEM C. 1e REGULAR UNLEADED ❑ 3 DIESEL ❑ 8 AVIATION OAS A ❑4 MOTOR VEHICLE FUEL 4 OIL B. C. ❑ 4 GASAHOL [:] 7 METHANOL ❑ 2 PETROLEUM ❑ 80 EMPTY E:] lb PREMIUM UNLEADED 1 PRODUCT ❑ tC MIDGRAOE UNLEADED ❑ 5 JET FUEL E:] B M85 ❑ 3 CHEMICALPRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE 2 LEADED ❑ 99 OTHER(DESCRIBE IN ITEM D.BELOW) 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 F❑T�LL I DOUBLE WALL F-13 SINGLE WALL WITH EXTERIOR UNER ❑ 5 INTERNAL BLADDER SYSTEM E:] 95 UNKNOWN SYSTEM 25-1 BJ --2 SINGLE WALL F-14 SINGLE WALL IN A VAULT ❑ 99 OTHER SC B. TANK J 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 8 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP (Pdmery Tak) ❑ 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 �-8 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES— NO— D.EXTERIOR ❑ 1 POLYETHYLENE WRAP 4&®-.2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC CORROSION ❑ ❑ 99 OTHER PROTECTION ❑ s CATHODIC PROTECTION F7 91 NONE 95 UNKNOWN SPILL CONTAINMENT INSTALLED(NEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) E.SPILL AND OVERFILL,BIC. DROP TUBE YES_ NO Com_ STRIKER PLATE YES_ NO DISPENSER CONTAINMENT YES_ NO IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A'J1 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLEPIPING A U 99 OTHER B. CONSTRUCTION A 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 1DO% METHANOL COMPATIBLE W/FRP PROTECTION A V 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER - 0. NECWHILAL IJ IFN( 2 ME ll K ss ❑3 LdIRMIWS wTERSTRUL ❑4 EIECTRWIC LDIE ❑5 AVTOIM9C%IIID ❑ 99 OTHER D. LEAK DETECTION ❑ DE =R ❑ TESIwI NCNTaWO LEAIf DEIECTOB sNrnwxH V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 REANUAL CONCILIATIONORY ❑ 3 MONI ORING VAOZE ❑ 4 GAUGING TANK E] 5 MONTORINGTER ❑8 TESTINGTANK ❑ 7 MON TI US G INTERSTITIAL ❑ 8 SIP ❑ 9 WE KL MANUAL ❑10 MOTHLY TANK �95 UNKNOWN ❑ 99 OTHER ESNG VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE M-PLACE) 1.ESTIMATED DATE LAST USED(MO/DAYNR) 2.ESTIMATED OUANTTY OF / 3.WAS TANK FILLED WITH YES ❑ NO ❑ L,y SUBSTANCE REMAINING �S GALLONS INERT MATERIAL? THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE qW OF MY KNOWLEDGE, IS TRUE AND CORRECT TANK OWNER'S NAME ^ ./I /1 DATE (PRINTED 4 SIGNATURE) 5 /9/ I /�/�\ Or ,.. f 2- /Og S• LOCAL AGENCY USE ONLY E STATE I.D.NUMBER ISJCOMPOSED OF E FOUR NUMBERS BELOW COUNTY M JURISDICTION# FACILITY# f TALK# STATE I.D.# L� PERMIT NUMBER PERMIT APPROVED BY/DATE 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 P FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE I ERGROUND STORAGE TANK REGULATIONS FORM B8.95) ,JJ' L