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.. STATE of CALIFORNIA STATE WATER RESOURCES CONTROL BOARD a 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 CLOSED ONSITE ONE ITEM 2 INTERIM PERMIT Q 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: # 3 7% I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A OWNERS TANK I.D.d /� B. MANUFACTURED BY: C. DATE INSTALLED(MOIDAY/YEAR) v D. TANK CAPACITY IN GALLONS: OD� 11.TANK CONTENTS IF A-1 IS MARKED,COMPLETE ITEM C. A 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C. to REGIAAR UNLEADED 3 DIESEL ❑ 6 AVIATION GAS ❑ 2 PETROLEUM ❑ 90 EMPTY ❑1 PRODUCT ❑ to PPAMM UNLEADED UNLEADEDQ 5 JGASAHOL L ❑ 8 M85? METHANOL ❑ 3 CHEMICALPRODUCT ❑ 05 UNKNOWN ❑ 2 WASTE MOGRADO ❑ 2 LEADED 99 OTHER(DESCRIBE M ITEM D.BELOW) D. IF(A1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED G A S d: 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 [Ef1 DOUBLE WALL ❑ 3 SINGLE WALL NTH EXTERIOR LINER O 5 MERNAL BLADDER SYSTEM ❑ 95 UNKNOWN SYSTEM ❑/2 SINGLE WALL ❑ 4 SINGLE WALL IN A VAULT ❑ 99 OTHER B. TANK LI 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM Q B 100% METHANOL COMPATIBLE W/FRP (Pftry Tank) ❑ 9 BRONZE Q 10 GALVANIZED STEEL ❑ 95 UNKNOWN O 99 OTHER C.INTERIOR ❑ 1 RUBBER LINED ,❑�2 AU(YO LINING ❑ 3 EPDXY UNING ❑ 4 PHENOUC LINING LINING OR ❑ 5 GLASS LINING U 8 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 E!r4 FIBERGLASS REINFORCED PLASTIC CORROSION PROTECTION ❑ 5 CATHODIC PROTECTION ❑ B1 NONE ❑95 UNKNOWN ❑ 99 OTHER E SPILLANO SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) OVERFILL,-ND•. DROP TUBE VES NO_ STRIKER PLATE YES ✓ NO_ DISPENSER CONTAINMENT YES ✓ NO l.. IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND,BOTH IF APPLICABLE TYPE— - A 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL AQLA 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)6)4 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL W/COATING A U B 100% METHANOL COMPATIBLE W/FRP PROTECTION A U B GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER D. 1 IFf111MDIL INE TEAK O 2 M IIaMItE5911GMIM39 1 8 UKOSA K PII1P O 99 OTHER V.TANK LEAK DETECTION L� ❑ 2 RMECONCILIAnONORY ❑ 3 VADOZE MONITORING 4 GAUGING TANK ❑ 5 MONITORINGOOUND TER O 6 ANNUALTESTING �7 aC�ONTINO000C3INTERSRDAL O B SIR ❑ 9 SEK Y MANUAL ❑10 MONTHLY TANK ❑ 95 UNKNOWN ❑99 OTHER V1.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) 1.ESTIMATED DATE LAST USED(MO/DAYNA) 2.ESTIMATED QUANTITY OF 1 3.WAS TANK FILLED WITH YES a NO❑ SUBSTANCE REMAINING GALLONS IN 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 pp7E (PRNTED A 9GNATIIRE) �OU6 M n 37, p o l0 /HILI/J!T/� - .� -I LOCAL AGENCY USE ONLY THE STATE ID.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY d JURISDICTION M FACILITY M TANK d STATE 04m L I 111(odP-110161if ' PERMIT NUMBER PERMIT APPROVED BYIDATE 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 PIAN. RLE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS FORM 8 (685) �-q Co / n .