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teovRces STATE OF CALIFORNIA c" " �O r STATE WATER RESOURCES CONTROL BOARD W� , UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B •Cil Ii01.N,�. COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY �1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ON SIT ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVE DBA OR FACILITY NAME WHERE TANK IS INSTALLED: - G = 4&;e=yt I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN j A OWNER'S TANK I.D.♦ I B. MANUFACTURED BY: 5 G O 1 ^nV C. DATE INSTALLED(MO/DAYNEAR) SQ(Z(^) �� D. TANK CAPACITY IN GALLONS: 7� � _tZ 0- 11. II.TANK CONTENTS IFA-1 IS MARKED,COMPLETE ITEM C. A Z�J_1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C. ❑ to REGULAR UNLEADED 3 DIESEL ❑ 6 AVIATION GAS ❑ 2 PETROLEUM ❑ 80 EMPTY �'1 PRODUCT ❑ 1PREMIUM UNLEADED ❑ 4 L ❑ 7 METHANOL ❑ 1cC JET FUEMIDGRADE UNLEADED ❑ 5 JET FUEL ❑ 8 M85 ❑ 3 CHEMICAL PRODUCT ❑ 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 PK 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 5 INTERNAL BLADDER SYSTEM ❑ 95 UNKNOWN �'1 SYSTEM ❑ 2 SINGLE WALL ❑ 4 SINGLE WALL IN A VAULT ❑ 99 OTHER w 1 B. TANK ❑ i 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 COMPATIBLE W/FRP (Primary Tank) ❑ 9 BRONZE ❑ 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 n 6 UNLINED ❑ 95 NKNOWN ❑ 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES NO— D.EXTERIOR ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP L?J�_4 FIBERGLASS REINFORCED PLASTIC CORROSION PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE I ❑95 UNKNOWN ❑ 99 OTHER E.SPILL AND OVERFILL,BtC. 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 U 1 SINGLE WALL A 2 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 A U 3 POLYVINYL CHLORIDE(PVC)AU 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 GALVANIZED STEEL A U 10 CATHODI ROTECTION A U 95 UNKNOWN U 99 OTHER MECHANICAL UNE LEAK 2 UNE TIGHTNESS 3 CONTINUOUS INTERSTITIAL 4 ELECTRONIC UNE 5 AUTOMATIC PUMP D. LEAK DETECTION 1 DETECTOR [:] TESTING MONITORING E] LEAK DETECTOR SHUTDOWN ❑ 99 OTHER V.TANK LEAK DETECTION �❑ VISUAL CHECK ❑ 2 RECONCILIATIONMANUAL ORY ❑ 3 MONITORING VADOZE 4 GAUGING AUTOMATIC TANK E] 5 MONITORING GROUND TER ❑ 6 TESTINGANNUALTANK 7 CON TORINWORN INTERSTITIAL ❑ 8 SIR ❑ 9 WEEK LY MANUAL ❑10 MONTHLY TANK [j95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) 1.ESTIMATED DATE LAST USED(MO/DAY/YR) e 1 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YE M S SUBSTANCE REMAINING GALLONS INERT MATERIAL? THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PER RY,A O THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT TANK OWNER'S NAME 1v/act -roN fcep_'jt,%'C4 TEDAT_E (PRINTED d SIGNATURE) �/) V - (A ,o's - LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS POS OF THE R NUMBERS BELOW COUNTY# JURISDICTION# FACILITY# TANK# 00 STATE I.DJ m F17F] 15 o 3w 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 STOR AGE TANK REGULATIONS FORM B (6-95) tp- /4- -