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tgouncps STATE OF CALIFORNIA r °o AP r STATE WATER RESOURCES CONTROL BOARD ; _ g UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B • OSI IFOR H,� ..y�L�,��5,(,rrrr COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY —i1 NEW PERMIT F73 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOS;E ONE ITEM 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED ! ' DBA OR FACILITY NAME WHERE TANK IS INSTALLED: �� (,Cg © j IQ fS(J j-4 cMr1&w4 F_�G I. TANK DESCRIPTION COMPLETE ALL ITEMS - SPECIFY IF UNKNOWN A. OWNER'S TANK I. D. # B. MANUFACTURED BY: Q je l/ L�/ C. DATE INSTALLED (MO/DAYNEAR) °µ ip r D. TANK CAPACITY IN GALLONS: II. TANK CONTENTS IF A-1 IS MARKED, COMPLETE ITEM C. p� �R 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C ❑ to REGULAR UNLEADED ❑ 3 DIESEL ❑ 6 AVIATION GAS ❑ 2 PETROLEUM ❑ 80 EMPTY 1 PRODUCT lb PREMIUM UNLEADED ❑ 4 GASAHOL ❑ 7 METHANOL ❑ 1c MIDGRADE UNLEADED ❑ 5 JET FUEL ❑ 8 M85 ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED ❑ 99 OTHER (DESCRIBE IN ITEM D. BELOM 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, 8, AND C, AND ALL THAT APPLIES IN BOX D AND E A. TYPE OF $Rr 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 4 STEEL CLAD W/ FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLEW/FRP (Primary Tank) ❑ g 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 6 UNLINED ❑ 95 UNKNOWN F799 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? , YES NO— INTERSTITIAL ❑4 ELECTRONIC LINE D. EXTERIOR ❑ 1 POLYETHYLENE WRAP f< 2 COATING El VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC CORROSION PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE ❑ 95 UNKNOWN E:] 99 OTHER E. SPILL AND OVERFILL CtC. SPILL CONTAINMENT_ INSTALLED (YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED (YEAR) DROP TUBE YES NO STRIKE 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 AU02 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) 9-U r 4 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL W/ COATING AU 8 100% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION D' MECHANICAL UNE LEAK [:] 2 UNE TIGHTNESS [:] 3 CONTINUOUS INTERSTITIAL ❑4 ELECTRONIC LINE �5 AUTOMATIC PUMP ❑ 99 OTHER DETECTOR TESTING MONITORING LEAK DETECTOR SHUTDOWN V. TANK LEAK DETECTION GROUND WANUAL F-1 1 VISUAL CHECK ❑ 2 RECONCILIATIONMANUAL INVENTORY [:]3 MONITORING VADOZE � GAUGING AUTOMATIC TANK ❑ 5 MON TORINGTER ❑ 6 TESTINGTANK k 7 CONTINUOUS MONITORING INTERSTITIAL ❑ 8 SIR E]9 TWEEKLY ANK GAUGING AL E::]10 TESTING E TINGY TANK ❑ 95 UNKNOWN a 99 OTHER VI. TANK CLOSURE INFORMATION (PERMANENT CLOSURE IN-PLACE) 1. ESTIMATEDATE LAST USED (MO/DAYNR) I 2. ESTIMATED SUBSTANCE UANTITY INI GF GALLONS 3 WAS TAN FILLEDMATERWITH YES E:] NO E:] 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 6 SIGNATURE) LOCAL AGENCY USE ONLY THE STATE I.D. NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW $eG X�.) COUNTY # JURISDICTION # FACILITY # TANK # 00 STATE I.D.4 1 1[,75-10 . y F el S PERMIT NUMBER 1p 3 f O PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE C� ► ?2 4 IlN I' 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 STORAGE TANK REGULATIONS FORMS (6-95) `� 11-30-M �°