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tyouAct� STATE OF CALIFORNIA Ar cO, STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B 1 S •CSL IIORNI COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ON SITE ONE ITEM 0 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ® 8 TANK R DBA OR FACILITY NAME WHERE TANK IS INSTALLED: ro' f'z 4 1411'7 I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A. OWNER'S TANK I.D.# �� i`r •�� B. MANUFACTURED BY: Ljn kYX?,jt7 C. DATE INSTALLED(MO/DAY/YEAR) 1Gi 762 D. TANK CAPACITY IN GALLONS: 000 II.TANK CONTENTS IF A-1 IS MARKED,COMPLETE ITEM C. A oq 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C Ella REGULAR UNLEADED ❑ 3 DIESEL ❑ 6 AVIATION GAS ❑ 2 PETROLEUM ❑ 80 EMPTY 1 PRODUCT D lb PREMIUM UNLEADED ❑ 4 GASAHOL ❑ 7 METHANOL 1c MIDGRADE UNLEADED ❑ 5 JET FUEL F-18 M85 ❑ 3 CHEMICAL PRODUCT E] 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED ❑ 99 OTHER(DESCRIBE IN ITEM D.BELOW) D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S.#: 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 r--] 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 5 INTERNAL BLADDER SYSTEM ❑ 95 UNKNOWN SYSTEM ® 2 SINGLE WALL ❑ 4 SINGLE WALL IN A VAULT ❑ 99 OTHER B. TANK 99 1 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 COMPATIBLEW/FRP (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER C.INTERIOR ED 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING LINING OR ❑ 5 GLASS LINING ❑ 6 UNLINED QQ 95 UNKNOWN ❑ 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO— D.EXTERIOR ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC CORROSION PROTECTION E:] 5 CATHODIC PROTECTION a 91 NONE ❑95 UNKNOWN ❑ 99 OTHER E.SPILL AND OVERFILL,CtC. SPILL CONTAINMENT INSTALLED(YEAR) 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 U 1 SUCTION A 2 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION A 671 SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND A&/l 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 STEELW/COATING A U 8 100% METHANOL COMPATIBLEW/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION =1 MECHANICAL LINE LEAK 2 LINE TIGHTNESS 3 CONTINUOUS INTERSTITIAL 4 ELECTRONIC LINE5 AUTOMATIC PUMP DETECTOR TESTING MONITORING LEAK DETECTOR [__1 SHUTDOWN F-1 99 OTHER V.TANK LEAK DETECTION VADOZE ypy�� ❑ 1 VISUAL CHECK ❑ 2 RECONCILMANUAL IATION ❑ 3 MONITORING 4 GAUGING MONITORING TANK ❑5 GROUND MONIfORINGTER ❑ 6 TESTING ❑ 7 MONITORCONTINUOUS ❑ 8 SIR ❑ 9 WEEK LY MANUAL E::]10 MOTESTINGHLY TANK ❑ 95 UNKNOWN ❑99 OTHER VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) 1.ESTIMATED DATE LAST USED(MO/DAY/YR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH SUBSTANCE REMAINING GALLONS INERT MATERIAL? YES F-1 NO❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT TANK OWNER'S NAMEG+�F &JZ;YlIVLO DATE (PRINTED b SIGNATURE) `_r r�� - 6. for Ow 1_.,y�Qy LOCAL AGENCY USE ONLY THE STATE I.D. B R IS MPOSED OF THE FOUR NUMBERS BELOW U tt✓ 1 ; COUNTY# JURISDICTION# FACILITY# �p� TANK# STATE I.D:# 341 ❑❑ ?j 1 b o �7" PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE r THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLIr 'IN-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. FO'-'e:MUST BE COMPLETED FOR INSTALL. SHOULD BE ACCOMPANIED BY A PLOT P� 'ILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE{ iGROUND STORAGE TANK REGULATIG. FORM B (6-95)