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C� 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 ❑ I NEW PERMIT O 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION O 7 PERMANENTLY CLOSED ONSITE ONE ITEM ❑ 2 INTERIM PERMIT 2r4 AMENDED PERMIT O 6 TEMPORARY TANK CLOSURE O 8 TANK REMOVED -0 p DBA OR FACILITY NAME WHERE TANK IS INSTALLED: Ef}OON --#7375/ 3A)nV I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A OWNER5 TANK I.D.I 'IJ7C/�/ B. MANUFACTURED BY: C. DATE INSTALLED(MOIDAYNEAR) �b 0. TANK CAPACITY IN GALLONS: 0000 II.TANK CONTENTS IF A-1 IS MARKED.COMPLETE ITEM C. A [El-1 MOTOR VEHICLE FUEL a 4 OIL B. C. to REGUWi UNIFADED 3 DIESEL ❑ 6 AVIATIONGAS ❑ 2 PETROLEUM O 80 EMPTY � PRODUCT ❑ 1E PREMMM UNLEADED 4 GASAHOL ❑ 7 METHANOL ED 1c MDGRADE UNLEADED ❑ 5 JET FUEL ❑ 8 M85 E] 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN E] 2 WASTE ❑ 2 LEADED O 99 OTHE MESCRIBEINREMD.B8-W D. IF(At)IS NOT MARKED. ENTER NAME OF SUBSTANCE STORED C.A S.f: Ill. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A B.AND C,AND ALL THAT APPLIES IN BOX D AND E A. TYPE OF IJ 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER O 5 INTERNAL BLADDER SYSTEM O 95 UNKNOWN SYSTEM ❑ 2 SINGLE WALL ❑ 4 SINGLE WALL IN A VAULT ❑ 99 OTHER B. TANK El-I BARE STEEL O 2 STAINLESS STEEL O 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP (MMUY Tmk) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL O 95 UNKNOWN ❑ 09 OTHER C.INTERIOR ❑ 1 RUBBER LINED O 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING LINING OR ❑ 5 GLASS LINING ET6 UNLINED ❑ 95 UNKNOWN a 99 OTHER COATING IS UNING 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 SPILL CONTAINMENT INSTALLED(YEAR) ffiOVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) 11 Ill it E.SPILL AND-OVERFILLIOI— DROP TUBE YES ✓ NO STRIKER PLATE YES NO_ DISPENSER CONTAINMENT YES I NO W.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND,BOTH IF APPLICABLE TYPE_ .– SUCTION ;W2 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL AOI 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)to4 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 A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER D. LEAK DE7ECTIW -01 IaowAOu LNE vAK ❑z uxE TKartraEu 3 wxlNuaus mlExsnruL 4 DECINONK uM: 5 Aurownc BM,P oA TEsrNa NoxIONx6 OJdt oElEOr� 91111WWC ❑ 99 OTHER V.TANK LEAK DETECTION ❑ VISUAL CHECK ❑ 2 RECONCILIATIONAL INVENTORY ❑ 3 MONITORING 4 GAUG NG C TANK ❑5 GAN TORIINGTER ❑6TESTINGTANK _.._..�7 MONITORINGCONTINUOUS INTERSTITIAL ❑ B SIR ❑ 9 WEEKGAMANUAL ❑ 10 M SNTHLY TANK O 95 UNKNOWN ❑ 99 OTHER TING VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) 1.ESTIMATED DATE LAST USED(MO/DAYNR) 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 BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT TANK OWNER'S NAME DOU! M CnoO _^ DATE (PRNTEDA SIGNATURET lP /!11` ��'IW_•H.Q.'/ 2^ qq LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY K JURISDICTION k FACILITY A TANK A STATE LD:# m 'L Z PERMITNUMBEFI PER MIT APPROVEDBYIDATE PERMIT EXPIRATION DATE V1 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 PLAN. FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS FORM B (695) j