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STATE OF CALIFORNIA • 4�"`y...+�.'roti STATE WATER RESOURCES CONTROL BOARD p g UNDERGROUND STORAGE TANK PERMIT APPLICATION-FORM B COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ON SITE ONE ITEM ❑ 2 INTERIM PERMIT F-1 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: ARCrJG 3 41 I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A. OWNERS TANK I.D.# 2 B. MANUFACTURED BY: eY� PS C. DATE INSTALLED(MO/DAYNEAR) 8 1 (�� D. TANK CAPACITY IN GALLONS: 2 OO U II.TANK CONTENTS IF A-1 IS MARKED,COMPLETE ITEM C. S \ 'C Z '006 g U Ste' A. 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C. 1. REGULAR UNLEADED ❑ 3 DIESEL ❑ 6 AVIATION GAS ❑ 1b PREMIUM UNLEADED ❑ 4 GASAHOL ❑ 7 METHANOL 2 PETROLEUM ❑ 80 EMPTY 1 PRODUCT 1c MIDGR.ADE UNLEADED ❑ 5 JET FUEL ❑ 6 M85 ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED ❑ 99 OTHER(DESCRIBE N ITEM D.BEL0m D. IF(Al)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A S.k III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A B.AND C.AND ALL THAT APPLIES IN BOX D AND E 1 DOUBLE WALLED3 SINGLE WALL NTH EXTERIOR A. TYPE OF LINER ❑ 5 INTERNAL BLADDER SYSTEM ❑ 95 UNKNOWN SYSTEM ❑ 2 SINGLE WALL ❑ 4 SINGLE WALL IINIA VAULT ❑ 99 OTHER B. TANK ❑ 1 BARE STEEL ❑ 2 STAINLESS STEEL rR_3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP (pr'MaryT-k) ❑ 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 �." UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO— D.EXTERIOR F-11 POLYETHYLENE WRAP „ w E] 2 COATING ❑ 3 VINYL WRAP _ 4 FIBERGLASS REINFORCED PLASTIC CORROSION t 6 ,., _7 .:..;,. PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE ❑95 UNKNOWN. ❑ 99 OTHER E SPILL AND OVERFILL etSPILL CONTAINMENT IN TALLED(YEAR) OVERFILL PFJ&VENTION EQUIPMENT INSTALLED(YEAR) + c, 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 ACU)2 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL ACU 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 A U 3 POLYVINYL CHLORIDE(PVC)AG4 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7'STEEL W/COATING A U 8 1001/6 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 ❑1 mE A' I-LINE LEAK ❑2 UNE TOMESS 3 CONTINUOUs INTEMTMAL 4 ELECTRaMC UNE AUTOMATIC PUMP DETECTOR TESTMO MONTORNO CfJUf DETECTOR sRUTDOWN ❑99 OTHER V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 MANUAL INVENTORY ❑ 3 ❑ 4 IC TANK ❑5 GROUND TER E:]6 TESTNTANK RECONCILIATIONMONIORING GAUGING MONITORING TESTING MON TOR NG INTERSTITIAL ❑ 8 SIR ❑ 9 TA EK GAUGINGAL ❑10 MONTHLY TANK ❑ 95 UNKNOWN ❑99 OTHER TESTING VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) 1.ESTIMATED DATE LAST USED(MO/DAYNR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH 7 SUBSTANCE REMAINING GALLONS I INERT MATERIAL? YES ❑ NO❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT TANK OWNER'S NAME ' ,� (PRINTED 8 SIGNATURE) f 1 1\`\`� \_C__ DATE 1G1�\L __ _ ��jj\_ LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS MPOSED OF THE FOUR NUMBis BELVW -1 STATE I.D:# COUNTY If JURISDICTION N FACILI M TANK R m 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 STORAGE TANK REGULATIONS FORM 5 (6-95) 0 Is