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-TY ' STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD ••• c°'o " 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 REM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED D DBA OR FACILITY NAME WHERE TANK IS INSTALLED: �j 3 O -T-►�yc�.q GB�,�, I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A OWNER'S TANK 1.D.K / B. MANUFACTURED BY: U. C. DATE INSTALLED(MO/DAYNEAR) 0. TANK CAPACITY IN GALLONS: �Q II.TANK CONTENTS IF A-1 IS MARKED,COMPLETE ITEM C. q, 1 MOTOR VEHICLE FUEL ❑ 4 OIL e_ C ❑ to REGULAR UNLEADED 3 DIESEL F—] 6 AVIATION GAS 2 PETROLEUM ❑ 80 EMPTY 1 PRODUCT ❑ :ab PREMIUM UNLEADED 4 GASAHOL ❑ 7 METHANOL ❑ tc MIDGRADE UNLEADED a 5 JET FUEL ❑ 8 M85 ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN 2 WASTE ❑ 2 LEADED ❑ 99 OTHER(DESCRIBE iN ITEM D.BELOW) D_ IF(A1)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 ❑ 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 5 INTERNAL BLADDER SYSTEM P;ZA-5 UNKNOWN SYSTEM ❑ 2 SINGLE WALL ❑ 4 SINGLE WALL IN A VAULT ❑ 99 OTHER B. TANK ❑ 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W1 FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL95 UNKNOWN ❑ 99 OTHER C.INTERIOR ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING LINING OR ❑ 5 GLASS LINING ❑ 6 UNLINED 5 UNKNOWN ❑ 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? S_ NO_ 0.EXTERIOR ❑ 1 POLYETHYLENE WRAP [7 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC CORROSION 1�,/� PROTECTION ❑ 5 CATHODIC PROTECTION C:] 91 NONE 1505 UNKNOWN ❑ 99 OTHER E SPILL AND OVERFILL,EtC, 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' 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 A U 2 DOUBLE WALL A U 3 LINED TRENCH 95 UNKNOWN A U 99 OTHER C. MATERIALAND A U 1 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 STEEL W COATING A U 8 100% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION 5 UNKNOWN A U 99 OTHER D. LEAK DETECTION ❑1 MEGU 1 LINE LEAK ❑2 LINE TI MEW ❑3 W(TIMM WMSTRIAL ❑4 ELECTROMC UNE ❑5 AUTOMATIC PUMP ❑ s9 OTHER DETECTOR TESTING MONITORING LEAK DETECTOR SHUTDOWN V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK 2 RECO CILIATIONUAL ORY ❑ 3 VADOZEMONITORING 4 GAUGING AUTOMATIC TANK ❑ 5 GROUND MONITORING TANK TESTING ❑ 7 MONITORINGCONTINUOUS NUOUS INTERSTITIAL 8 SIR ❑ 9 WEEKGAYUMANUAL ❑10 MONTHLY TANK ❑ 95 UNKNOWN 99 OTHER VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) t.ESTIMATED DATE LAST UfED(Mr10 R) 2 ESTIMATED QUANTITY OF 0 3.WAS TANK FILLED WITH YES ❑ NO❑ R 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 DATE (PRINTED b SIGNATURE) LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY# TANK# ,T.�- STATE I.Dl I I I PERMIT NUMBER PERMIT APPROVED BYIDATE PERMIT EXP,IIR_AT1pN DATE THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPUCATTnN-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. FOR}I�MUST BE COMPLETED FOR INSTALLATIONS.THIS FORM SHOULD BE ACCOMPANIED BY A PLOT PL I-ETHIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE GROUND STORAGE TANK REGULATIONS FORM B (6-95)