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STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM B COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY f__1 1 NEW PERMIT Fj 3 RENEWAL PERMIT F 5 CHANGE OF INFORMATION F__j 7 PERMANENTLY CLOSED ON SITE ONE ITEM 0 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: Ae-*w ZV4 I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A. OWNER'S TANK I.D.# B. MANUFACTURED BY: C. DATE INSTALLED(MO/DAY/YEAR) z D. TANK CAPACITY IN GALLONS: II.TANK CONTENTS IF A-1 IS MARKED,COMPLETE ITEM C. A. ce 1 MOTOR VEHICLE FUEL F__] 4 OIL B. C. F-1 to REGULAR UNLEADED F -'13 DIESEL [::] 6 AVIATION GAS F_� 2 PETROLEUM E] I 80 EMPTY PRODUCT D lb PREMIUM UNLEADED ff 4 GASAHOL E:] 7 METHANOL F_j Ic MIDGRADE UNLEADED E:j 5 JETFUEL E] 8 M85 ❑ 3 CHEMICAL PRODUCT El 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.#: Ill. 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 F-] 95 UNKNOWN SYSTEM 2 SINGLE WALL E 4 SINGLE WALL IN A VAULT ❑ 99 OTHER B. TANK ❑ 1 BARE STEEL 0 2 STAINLESS STEEL 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL F-] 5 CONCRETE F__j 6 POLYVINYL CHLORIDE 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLEW/FRP (Pdmary Tank) 0 9 BRONZE E] 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER C.INTERIOR ❑ 1 RUBBER LINED F-1 2 ALKYD LINING r__j 3 EPDXY LINING ❑ 4 PHENOLIC LINING LINING OR F-1 5 GLASS LININGT 6 UNLINED F-]4 UNKNOWN F__j 99 OTHER COATING IS LINING MATERIAL COMPATIBLETH 009% METHANOL? YES NO— D.EXTERIOR F-1 I POLYETHYLENE WRAP 2 COATING 3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC CORROSION I PROTECTION 0 5 CATHODIC PROTECTION ❑ 91 NONE ❑95 UNKNOWN 99 OTHER SPILL CONTAINMENT INSTALLED(YEAR) "I FL OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) E.SPILL AND OVERFILL,etc. 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 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL ACt,4DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND A U I BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A' 4 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL WICOATING A U 8 100% METHANOL COMPATIBLEWIFFIP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION g MECHANICAL LINE LEAK F--]2 LINE TIGHTNESS Lg3 CONTINUOUS INTEMMIAL [:]4 tEEEr DETECTOR LINE CTOR N!AUTOMATIC PUMP DETECTOR TESTING MONITORING SHUTDOWN E] 99 OTHER V.TANK LEAK DETECTION W VISUAL CHECK ❑ 2 MANUAL INVENTORY E] 3 VADOZE ❑ 4 AUTOMATIC TANK ❑5 GROUNDWATER ❑6 ANNUALTANK F1 0 RECONCILIATION MONITORING GAUGING MONITORING TESTING 7 CONTINUOUS MONITORING TAINTERSTITIAL [::] 8 SIR ❑ 9 WENK EKLY MANUAL F_�10 MOTESTING NTHLY TANK ❑ 95 UNKNOWN ❑99 OTHER GAUGING V1.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) 1.ESTIMATED DATE LAST USED(MO/DAY/YR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YESENO SUBSTANCE REMAINING —GALLONS 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&SIGNATURE) LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW STATE I.D.4 COUNTY# JURISDICTION# FACILITY# TANK PERMIT NUMBER PERMIT APPROVED BYIDATE PgRMIT ERPRQQ�N ON THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLIC TION-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. F MUST BE COMPLETED FOR INSTALLATIONS.THIS FORM SHOULD BE ACCOMPANIED BY A PLOT P LE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THEWRGROUND STORAGE TANK REGULATIONS FORM 8 (6-95)