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• 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 CLOSE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: /eq vjr ILS SF �G 7 C��.3 I (• I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A OWNER'S TANK L D.N B. MANUFACTURED BY: �0 C. DATE INSTALLED(MOIDAYNEAR) tj D. TANK CAPACITY IN GALLONS: r II.TANK CONTENTS IF A-1 IS MARKED,COMPLETE ITEM C. A. MOTOR VEHICLE FUEL E] 4 OIL B. C. le REGULAR UNLEADED ❑ 3 DIESEL ❑ 6 AVIATION GAS 2 PETROLEUM ❑ 80 EMPTY 1 PRODUCT ❑ 1B PREMIUM UNLEADED [:] 4 GASAHOL ❑ 7 METHANOL ❑ iC MIDGRADE UNLEADED ❑ 5 JET FUEL ❑ B M85 ❑ 3 CHEMICALPRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE 2 LEADED ❑ 99 OTHER(DESCRIBE IN ITEM D.BELOW) D. IF(AI)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S.x: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A,B AND C.AND ALL THAT APPLIES IN BOX D AND A. TYPE OF I❑7 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR UNER ❑ 5 INTERNAL BLADDER SYSTEM ❑ 95 UNKNOWN SYSTEM iQ'2 SINGLE WALL ❑ 4 SINGLE WALL IN A VAULT ❑ 99 OTHER B. TANK 0� 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 (PrIm9rYTmk) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER C.INTERIOR ❑ I RUBBER UNED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING UNINGOR ❑ 5 GLASS LINING 6 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO- D.EXTERIOR ❑ I POLYETHYLENE WRAP C62-2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC CORROSION ❑ 91 NONE E]95 UNKNOWN ❑ 99 OTHER PROTECTION r75 CATHODIC PROTECTION E SPILL AND OVERFILL,BCC. SPILL CONTAINMENT INSTALLED(YEfR) OVERFILL PREVEN710N 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 U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION A 1 SINGLE WALL A U 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)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 Affl 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER ❑ D. LEAK DETECTION ❑1 MECIWAM UNE IJ J 2 NNE TIGN1NE55 3 C 141JWS NIERS 4=CUM ❑5 AIAMM11C PUMP ❑ 99 OTHER of _ aw ❑ TE3TNG MOMI'MING ❑ LEAN oETEc1OR sNurowm V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 RECNUAL ONCIUATIONORV ❑ 3 MONITORING ZIE ❑ 4 GAUGINGAUTOMATIC TANK ❑5 MON TORINGGROUND TER E:] 8 TESTINGTANK ❑ 7 MONITORING INTERSTITIAL [D 8 SIR ❑ 9 TANEKGAU INGAL ❑ 10 MONTHLT STINGY TANK jTJCI 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PUCE) 1.ESTIMATED DATE LAST USED(MC/DAY/YR) 2.ESTIMATED QUANTITY OF 3,WAS TANK FILLED WITH YES ❑ NOZ�, SUBSTANCE REMAINING _GALLONS INERT MATERIAL? THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO rHEIBES Fxjy KNOWLEDGE,IS TRUE AND CORRECT TANK OWNER'S NAME DATE �] (PRNTED&SIGNATURE) /11 t LOCAL AGENCY USE ONLY E STATE I.D.NUMBER IS COMPOSED OF AE FOUR NUMBERS BELO COUNTY N JURISDICTION N FACILITY N TANK N QO STATE I.D.# c L_J__LJ 1 R D IV 1311 PERMIT NUMBER PERMIT APPROVED BYIDATE PERMIT EXPIRATION DATE I 7 Yt 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 ACCOMPANIEDBYA�PLOT PLAN. .FILE -/THIS yFORM WITHTHELOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATI0�15� FORM B (6') /o- ] �� v .2-a