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0 s W STATE OF CALIFORNIA ' "'•• STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION-FORM B 'c'+l IRO1lMR COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLPSEDfMW ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE 8 TANK RE DBA OR FACILITY NAME WHERE TANK IS INSTALLED: Q I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A OWNER'S TANK I.D.# � a /A fe. o/-/ B. MANUFACTURED BY: C. DATE INSTALLED(MO/DAY/YEAR) g V V L D. TANK CAPACITY IN GALLON-S: 11.TANK CONTENTS IF A-1 IS MARKED,COMPLETE ITEM C. A, ❑ 1 MOTOR VEHICLE FUEL 4 OIL B. C. ❑ to REGULAR UNLEADED ❑ 3 DIESEL ❑ 6 AVIATION GAS ❑ lb PREMIUM UNLEADED ❑ 4 GASAHOL E] 7 METHANOL 2 PETROLEUM ❑ 80 EMPTY ❑ 1 PRODUCT � 1c MIDGRADE UNLEADED ❑ 5 JET FUEL ❑ 8 M85 ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN Siz 2 WASTE ❑ 2 LEADED E' 99 OTHER(DESCRIBE IN ITEM D.SELOM D. IF(A 1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STOREDw6lig_ cr;/G, 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 A i 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 ❑ B 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 6 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO— D.EXTERIOR ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC CORROSION PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE ❑95 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 U i SUCTION A U 2 PRESSURE A 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 A U 95 UNKNOWN ACtJD 99 OTHER C. MATERIAL AND 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 A U 95 UNKNOWN A(2)99 OTHER D. LEAK DETECTION Jul DETECTOR TESTING ❑ MONITORING ❑ LEAK DETECTOR ❑ SHUTDOym 99 OTHER V.TANK LEAK DETECTION Zx1 VISUAL CHECK ❑ 2 MANUAL RECONCILIATIONINVENTORY ❑ 3 MONIITORING OZE ❑ 4 GAUGING AUTOMATIC TANK ❑5 GROUND MONITORING TER ❑ 6 ANNUAL TESTING ❑ 7 MONITOR CONTINUOUS INTERSTITIAL ❑ B SIR ❑ 9 TANEKLY K GA MANUAL ❑10 MO TINLY TANK E] 95 UNKNOWN ❑99 OTHER A TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) 1.ESTIMATED DATE LAST USED(MO/DAYNR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES E] NO SUBSTANCE REMAINING •? GALLONS INERT MATERIAL 7 THIS FORM HAS BEEN COMPLETED UNDER PEYALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT TANK OWNER'S NAME DATE (PRINTFJ)3SIGNATURE) _ LOCAL AGENCY US N THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY# TANK# STATE I.D:# m Mo PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE to-n_" :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 PLFU E THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE U ROUND STORAGE TANK REGULATIONS FORMS (6.95)