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STATE OF CALIFORNIA = '� °.� ` STATE WATER RESOURCES CONTROL BOARD p�� e UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY 71 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ONE REM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED / 9 DBA OR FACILITY NAME WHERE TANK IS INSTALLED: j J!`� T £ S£/Z If/G .�L�� i Al, �LZJz S'r / I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A OWNER'S TANK I.D.a B. MANUFACTURED BY: c';'d "v / C. DATE INSTALLED(MO/DAYNFAR) 1, /<;v0 D. TANK CAPACITY IN GALLONS: N D II.TANK CONTENTS IF A-1 IS MARKED,COMPLETE ITEM C. A fig-L MOTOR VEHICLE FUEL ❑ 4 OIL B. C. a REGUUR UNLEADED E] 3 DIESEL E] 6 AVIATION GAS F-12 PETROLEUM ❑ 80 EMPTY �1 PRODUCT 1b PREMIUM UNLEADED a 4 GASAHOL ❑ 7 METHANOL ❑ 3 CHEMICALPRODUCT ❑ 95 UNKNOWN ED 2 WASTE ❑ 1C MIDGRADE UNLEADED ❑ 5 JETFUEL ❑ 8 M85 2 LEADED [1] 99 OTHER(DESCRIBE IN ITEM D.BELOW) D. IF(A1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S.0: 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 ❑ 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 5 INTERNAL BLADDER SYSTEM E] 95 UNKNOWN SYSTEM �2 SINGLE WALL ❑ 4 SINGLE WALL IN A VAULT ❑ 99 OTHER B. TANK1 BARE STEEL F72 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL c5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP (Primary Twk) ❑ 9 BRONZE O 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER C.INTERIOR ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC UNING LINING OR ❑ 5 GLASS LINING �6 UNLINED a 95 UNKNOWN ❑ 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO— D.EXTERIOR O 1 POLYETHYLENE WRAP COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC CORROSION PROTECTION ❑ 5 CATHODICPROTECTION D 91 NONE ❑ 95 UNKNOWN O 99 OTHER E.SPILL AND OVERFILL,6LC. SPILL CONTAINMENT INSTALLED R) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) DROP TUBE YES NO 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 6 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION A O 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 U5 ALUMINUM A U 6 CONCRETE A U 7 STEEL W/COATING A U a 100% METHANOL COMPATIBLE W/FRP PROTECTION A09 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION1 MEQVMCEL LINE 2 UNE U'llt 1Na M 3 CGMINWIIS WTEAST C9XNIC UNE 5 AIAO A11C NEO ❑ OE mol ❑ TESTING ❑ MONTg11NG E]4 ELEIFAIt OETECT011 ❑ SNU ffl ❑ 99 OTHER V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 RMECO CILIATIONUAL ORY ❑ 3 M�TORING ZE ❑ 4 GAUGINAUTOMATG TANK ❑5 MONITORINGROUND G ❑ 6 TESTINGANNUAL ❑ 7 MONITORING INTERSTITIAL ❑ B SIR ❑ 9 WEEK LY MANUAL ❑10 MONTHLY TANK �q5 UNKNOWN ❑99 OTHER TING VL TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PUCE) 1.ESTIMATED OATS LAST USED(MO/DA NR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES O NOam' SUBSTANCE REMAINING GALLONS INERT MATERIAL? i THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BES7 OF MY KNOWLEDGE,IS TRUE AND CORRECT TANK OWNER'S NAME DATE (PRINTED a SIGNATURE) / / 4. f® LOCAL AGENCY USE ONLY THE TATE I.D.NUMBER IS COMPO ED OF THE FOUR NUMBERS LOW COUNTY M JURISDICTION M FACILITY TANK a Q STATE I.D.# LO FTT� s 0I 0 8 3 PERMIT NUMBER PERMIT APPROVED BYIDATE PERMIT EXPIRATION DATE THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORMA,UNLESS A CURRENT FORMA HASBEENFILED. FORM C MUST BE COMPLETED FOR INSTALLATIONS. THISFORM SHOULD BE ACCOMPANIED BY A PLOT P RLE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE yTANK yyREGULATIONS FORM 8 (S95)