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STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD •` UNDERGROUND STORAGE TANK PERMIT APPLICATION-FORM B t' ~ _ w oe COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. " MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ •LOS D ONE ITEM ❑ 2 INTERIM PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ON SITE �4 AMENDED PERMIT ❑ e TEMPORARY TANK CLOSURE ❑ Q B TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: I. TANK DESCRIPTIONV COMPLETE gLLITEMS- SPECIFY IF UNKNOWN y A OWNERS TANK I.D.f 3756-2 B. MANUFACTURED BY: C. DATE INSTALLED(MOADAY/YEAR) D. TANK CAPACITY IN GALLONS: 1000 II.TANK CONTENTS IFA-11SMARKED,COMPLETE ITEM C. A EJ ' MOTOR VEHICLE FUEL ❑ I OIL S, EEf�—IPA�OD C 17�y1a REGULAR UNLEADED 3 DIESEL ❑ 8 AVIATIONGAS ❑ 2 PETROLEUM ❑ 80 EMPTY CT EEI1E PREMIUM UNLEADED g 4 GASAHOL ❑ 7 METHANOL ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ Ic MDGRADE UNEADED 5 JET FUEL ❑ B M65 ❑ 2 LEADED H 99 OTHER(OESCRBE N OEM D BE OM D. IF(At)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.AS.f: III. TANK CONS�TRRUUCTION MARK ONE ITEM ONLY IN BOXES A,B,AND C.AND ALL THAT APPLIES IN BOX D AND E A. TYPE OF LJ 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER 05 INTERNAL BLADDER SYSTEM ❑ ❑ 95 UNKNOWN SYSTEM ❑ 22 SINGLE WALL t SINGLE WALL IN A VAULT E::] 99 OTHER B. TANK Eg ' BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CID W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP (PHOIW To) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ g9 OTHER C.INTERIOR ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING LINING OR ❑ 5 GLASS LINING [;J� UNLINED _] 95 UNKNOWN ❑ gg OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 10D% METHANOL? YES_ NO— D.EXTERIOR ❑ ( POLYETHYLENE WRAP 2 COATING CORROSION ❑ ❑ 3 VINYL WRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE 0 9 UNKNOWN ❑ 99 OTHER SPILL CONTAINMENTI ALLED(YEAR) OVER FlLLP EVENTION EQUIPMENTINSTALLED(YEAR) ESPILL AND OVERFILL,ete. DROP TUBE YES ' TKO_ 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& 2 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A U95 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�D) 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 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION 1 WOx uLA ❑2 Tw+1Nss caxrrA/ws mERsmw BEcm9wc urrE s AurawTK wry oElECfdl iE311No Moira LF.1K oEfECT011 ❑ SMRWMN ❑ 99 OTHER V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 RMANUAL IJATINVENTONORY ❑ 3 VADOZE MONITORING 4 AUTOOMATIC ING TANK ❑ 5 ON ND WATER E::) 6 TESTING 2f7 CONTINUONG US INTERSTITIAL ❑ 8 SIR ❑ 9 WEEKLY MANUAL ❑10 MONTHLY TANK ❑ 95 UNKNOWN ❑ 99 OTHER TANK GAUGING TESTING VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) 1.ESTIMATED DATE UST USED(MO/DAY/YR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH SUBSTANCE REMAINING GALLONS I INERT MATERIAL YES ❑ NO❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT TANK OWNER'S NAME DATE B SIGNAURE) �IoUG MA55RnD rr- 3o -19 LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY f JURISDICTION f FACILITY X TANK* STATE I.D.# m I I I I I I I ti f 31 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 PLAN. FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS FORM 8 (695)