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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 i NEW PERMIT 3 RENEWAL PERMIT ❑ g CHANGE OF INFORMATION a 7 PERMANENTLY CLOSED ONSITE ONE ITEM ❑ 2 INTERIM PERMIT ® 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: RCC) G> Cg 3 I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A. OWNERS TANK 1.D.1 2 .8. MANUFACTURED BY: C. DATE INSTALLED(MO/DAY/YEAR) g,0$ (�� =r. D. TANK CAPACITY IN GALLONS: 7' 1 Z OO U II.TANK CONTENTS IF A-1 1S MARKED,COMPLETE ITEM C. 4 S \V- 2 1. `(�0 1 MOTOR VEHICLE FUEL ® 4 OIL B, C. to REGULAR UNLEADED 3 DIESEL E]A, 6 AVIATION GAS ib PREMIUM LU14DED 4 GASAHOL ❑ 7 METHANOL ❑ 2 PETROLEUM ❑ BO EMPTY ,�t PRODUCT 1c MIDGA4DE UNLEADED g JET FUEL ❑ 8 MBS 3 CHEMICAL PRODUCT 95 UNKNOWN 2 WASTE 2"LEADED ❑ 99 OTHER(DESCRIBE IN ITEM D.BELOW) D. IF(Al)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S.Ai' .. Ill. TANK CONSTRUCTION `-MARK ONE TEM ONLY IN BOXES A.B. C.AND ALL THAT APPLIES IN BOX D AND E �5 i DOUBLE WALL 3 SINTH LINE GLE~WALL WEXTERIOR R A. TYPE OF - � 0 • _ ❑ S_ 9JTERNAL BLADDER SYSTEM ® 95 UNKNOWN SYSTEM ❑ 2 SINGLE WALL O 4 SINGLE.WALLINA VAULT ❑ 99 OTHER I BARE STEEL 2 STAINLESS STEEL 3 FIBERGLASS 4 STEEL CLAD.W/FIBERGLASS REINFORCED PLASTIC B. TANK ❑ � ❑ MATERIAL ❑ 5 CONCRETE Q 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 6 100 METHANOL COMPATIBLE WIFRP (Primary TAW ❑ 9 BRONZE Q 10 GALVANIZED STEEL ® 9S~UNKNOWN :❑ 99'OTHER V h w C.INTERIOR 1 RUBBER LINED 2 ALKYD LINING ❑ 3 EPDXY LINING '4 PHENOUC'LINING !: LINING OR ❑ 5 GLASS LINING �8 UNUNED3: ® 95`UNKNOWN ® ` ... . `:. , _ 99 OTHER IS _ COATING .:�, .. .. . ,' LINING MATERIAL COMPATIBLE WITH 100%METHANOL? YES_,NO_ D.EXTERIOR ® CORROSION 1 POLYETHYLENE WRAP ® 2--COATING', 3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ g CATHODIC PROTECTION ® 91 NONE_ ❑9s UNKNOWN; ❑ 99 OTHER. SPILL CONTAINMENT INSTALLED(YEAR) - OVERFILLPf3FiVENT10 EQUIPMENT INSTALLED(YEAR) E SPILL AND OVERFILL,etc. DROP TUBE YESy 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 U 2 PRESSURE '-� A U 3 GRAVITY A'U',-4 FLEXIBLE PIPING-'k*U"99'OTHER B. CONSTRUCTION A U 1 SINGLE WALL AU 2 DOUBLE WALL'••i A U 4 LINED TRENCH A U 9 95-UNKNOWN A U 99 OTHER C. MATERIAL AND A U 1 BARE STEEL A U 2 STAINLESS STEEL n A U 3 POLYVINYL CHLORIDE(PVC)A(T)4 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 6 CONCRE'T'E"' ,A U 7�STEEL WICOATING A U 6 100%METHANOL COMPATIBLE WIFRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION ®1 ME0WrA UNE LW ❑2 UNE 1KMITRESS 3 wrmman�r+smuL 4 ELECIRaae Le,E Alrtowenc PM CE1ECiWi tEsmao Worarr>artw .... ,IEAK oE1EC1+oR _ sHlrrOoyvrd ..• ❑99 OTHER V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 RECONCILIATION INVENTORY ❑ 3 MONITORING ® 4 AGA�MAG C TANK ❑5 MONITORINGTER 8 TE�NGTANK rrOCONTINUOU'S INTERSTITIAL ❑ 8 SIR ❑ 9 TAN WEEKLY MANUAL❑ 10 UGi TESTING GLY TANK ® 95 UNKNOWN a 99 OTHER VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE INwPL►CE) 1.ESTIMATED DATE LAST USED(MOIDAYNR) 2.ESTIMATED OUANTITY OF 3.WAS TANK FILLED WITH SUBSTANCE REMAINING GALLONS INERT MATERIAL T YES NO❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUEL AND CORRECT (PRINM&SISI LASURE) E \Ccs.. �_ DATE Lv,��`►� LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS MPOSED OF THE FOUR NUMB S BEL W COUNTY I JURISDICTION N FACILI ,N ' TANK R STATE I.D:# m FTT] Ll I I I I 1 11� PERMIT NUMBER PERMIT APPROVED BYIDATE 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 P RLE THIS FORM WITH THE LOCAL AGENCY WLawn=THE JVD STORAGE TANK REGULATIONS FORM B (6-9g)