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STATE OF CALF OFINIA STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION-FORM B COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ❑ I NEW PERMIT n 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 0 INSTALLE11k I. TANK DESCRIPTION COMKETE ALL ITEM- SPWFY IF UNKNOWN A. OWNERS TANK 1.D.0 B. MANUFACTURED BY: Lt C. DATE INSTALLED(MOMAYASAR) Ug r D. TANK CAPACITY IN GALLONS: 11.TANK-COINTENTS IF A-1 18 MARKED.OOMIKETS ITEM C. A 1 MOTOR VEHICLE FUEL 4 OILS. C, la RRMAR-F34, URI 3 DIESEL [7 6 AVIATtONGAS AM r7 2 PETROLEUM F-1 90 EMPTY 121,1 PRODUCT lb PREMIUM UNLEADED 4 GASAHOLp 7 METHANOL Ic MOGRADE LKMXP 5 JET FUEL H a Abs ❑ 3 CHEMICAL PRODUCT 06 UNKNOWN 2 WASTE E:D 2 LEADED 99 OTHER WWRISE IN ITEM D.BBDM D. IF(A.1)18 NOT MARKED.ENTER NAME OF SUBSTANCE STORED C.A.S.0: Ill. TANK CONSTRUCTION MARK ONE rmm ONLY IN BOXES A.B.AND C.AND ALL THAT APPLIES IN BOX D AND E A. TYPE OF 13 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER 5 INTERNAL BLADDER SYSTEM E3 95 UNKNOWN SYSTEM fiRL 2 SINGLE WALL ❑ 4 SINGLE WALL IN A VAULT ❑ 99 OTHER IIN:m B. TANK i BARE STEEL ❑ 2 STAINLESS STEEL 3 FIBERGLASS 4 STEEL CLAD Wl FIBERGLASS REINFORCED PLASTIC )Inj MATERIAL ❑ 5 CONCRETE 6 POLYVINYL CHLORIDE 7 ALUMINUM 8 100% METHANOL COMPATIBLE W/FRP TW4 9 BRONZE 10 GALVANIZED STEEL 95 UNKNOWN 99 OTHER C. AOR ❑ I RUBBER LINED 2 ALKYD LINING 3 EPDXY LINING 4 PHENOLIC LINING Lumon 5 MASS LINING 0 UNLINED 06 UNKNOWN 90 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 1011%METHANOL? YES— NO— MEXTERIOR I POLYoWfLEW WRAP 2 COATING 3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC CMOs" PROTECTION ❑ 5 CA PROTECTION 91 NONE ❑00 UNKNOWN ❑ 99 OTHER SPILL CONTAINMENT INSTALLED(YEAR)— OVERFILL PREVENTION EOUIPMENT INSTALLED(YEAR) E SPILL AND OVERFILL,etc. DROP TUBE YES� NO— STRIKER PLATE YES— NO— DISPENSER CONTAINMENT YES::-.- NO IV.PIPING INFORMATION CWCLE A IF ABOVE GROUND OR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYMM TYPE A U 1 SUCTION A 6)2 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION An I SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U to OTHER C. MATERIAL AND A&)l BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A U 4 FIBERGLASS PIPE Como$" A U a ALUMINUM A U 6 CONCRETE A U 7 STEEL W/COATING A U a i00% METHANOL compAneLEwFRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER OTHER Zfl MOWW&U14 ol 3 WMAJOA WNWRIAL ❑4 ELEM140mc UNE 0" WN U"' 99 D. LEAK DETECTION 2-0m WNMwo LIM DETECTOR swTDO V.TANK LEAK DETECTION ❑ I VISUAL CHECK 2 MANUAL INVENTORY 3 VADOZE 4 AUTOMATIC TANK ❑5 GROUND WATEA ANNUALTANK RECONCILIATION MONITORING GAUGING MONITORING 6-- TESTING 3 1❑ 7 CON71N000S INTERSTITIAL 8 SIR 9 WEEKLY MANUAL 10 MONTHLY TANK 95 UNKNOWN ❑99 OTHER V1.TANK CLOSURE INFORMATION mEmANENT CLOSURE iN*LACE) 1.ESTIMATED DATE LAST USED MOGAYNR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YESNO r-A SUBSTANCE REMAINING INERT MATERIAL? F7 THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT TANK OWNERS NAME DATE ow4wo&somrim-01-1 7- 1 LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY 0 JURISDICTION 0 FACILITY 0 TANK 0 STATE I.D. = = I I I -T-FT] QI TT- PERMIT NUMBER I PERMIT APPROVED BYIDATE I 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 NAPLENIENTINOI THE UNDERGROUND STORAGE TANK REGULATIONS FORM et H 0 0