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Nso STATE OF CAUFORNIA STATE WATER RESOURCES CONTROL BOARDCS ; 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 ON SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A. OWNER'S TANK I.D.M _ B. MANUFACTURED BY: C. DATE INSTALLED(MO/DAYNEAR) 9�,7 .,C' D. TANK CAPACITY IN GALLONS: II.TANK CONTENTS IF A-1 IS MARKED,COMPLETE ITEM C. p` N�1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C. ❑ is REGULAR UNLEADED ❑ 3 DIESEL ❑ 6 AVIATION GAS ❑ 2 PETROLEUM ❑ 80 EMPTY 1 PRODUCT ❑ " PREMIUM UNLEADED ❑ 4 GASAHOL ❑ 7 METHANOL ❑ IC MIDGRADE UNLEADED ❑ 5 JET FUEL ❑ 8 M85 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED El-e 99 OTHER(DESCRIBE IN REM D.BELOW) D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED /19 ! .2 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 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 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS u 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP (Primary Tank) ❑ 9 BRONZE a 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER C.INTERIOR ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING LINING OR ❑ 5 GLASS LINING S� 6 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 ❑ 4 FIBERGLASS REINFORCED PLASTIC CORROSION PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE ❑ 95 UNKNOWN 99 OTHER PILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) E.SPILL AND OVERFILL,etc. DROP TUBE YES NO S RIKER PLATE YES NO� DISPENSER CONTAINMENT YES->5-_ NO W. PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION A a2 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL AQ Z 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 A63 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 3 100% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER MECHANICAL UNE LEAK 2 UNE TIGHTNESS CONTINUOUS INTERSTMAL 4 ELECTRONIC LINE 5 AUTMA OTIC RUMP D. LEAK DETECTION DETEcrGR ❑ TESTING MONITORING ❑ LEAK DETECTOR ❑ SHUTDOWN [:] 99 OTHER V.TANK LEAK DETECTION -71 t VISUAL CHECKSZ: 2 RECONCILIATIONMANUAL INVENTORY ❑ 3 MONIITORING l�VAOZEd GAUD NGAUTOMATIC TANK ❑ 5 MONITORING GROUND WATER [:] 6 TESTINGTANK 7 CONMON INUOU INTERSTITIAL [:] 8 SIR ❑ 9 TANKLY MANUAL ❑ 10 MONGING THLY TANK❑ 95 UNKNOWN F7 99 OTHER ORINNG 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 YES SUBSTANCE REMAINING 1--//4' GALLONS INERT MATERIAL 1 THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT TANK OWNER'S NAMEDATE (PRINTED 6 SIGNATURE) ?/Z/,- ti" ITJ� G Gp/ _� Io LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OFTHE FOUR NUMBERS BELOW COU�NTY1# JURISDICTION# FACILITY# TANK# STATE I.D: 14 =5C 3 II PERMIT NUMBER I PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATIC''- "ORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. FORM C W—T BE COMPLETED FOR INSTALLATIONS. THIS/FORM SHOULD BE ACCOMPANIED BY A PLOT PI' ' HIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE I"'^E IJND STORAGE TANK REG OSS `goRR7 FORMS (6-95) ( �I/` tl? 4111/qir