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STATE OF CALIFORNIA ! ti STATE WATER RESOURCES CONTROL BOARD 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 ❑ 4 AMENDED PERMIT ® 8 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: I. TANK DESCRIPTION COMPLETE ALL ITEMS—SPECIFY IF UNKNOWN A OWNERS TANK 1.D.• 3 ` B MANUFACTURED BY: S C. DATE INSTALLED(MO/DAY/YEAR). �� % D. TANK CAPACITY IN GALLONS: II.TANK CONTENTS IF A-1 IS MARKED.COMPLETE ITEM C. A. 1 MOTOR VEHICLE FUEL ❑ 4 OIL B M _ C.' 18 REGULAR UKMED 3 DIESEL ❑ 6 AVIATION GAS ® 2 PETROLEUM 80 EMPTY ° 1 PRODUCT lb PREMIUM ON.EADED 4 GASAHOL ❑ 7 METHANOL® IO t)IDGFIADE UNLEADED5 JET FUEL ❑ 8 M85 ❑ 3 CHEMICAL.PRODUCT ® 95 UNKNOWN ❑ 2 WASTE "® 2 LEADED H 99 OTHER(DESCRBE N ITEM 0.BELOW) D. IF(A.1)IS NOT MARKED.ENTER NAME OF SUBSTAGE STORED C.-A.S f _; III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.S.AND C.AND ALL THAT APPLIES IN BOX D AND E _ "' 3 SINGLE WALLWITH EXTERIOR UNER 5 INTERNAL BLADDER SYSTEM 95 UNKNOWN 1 DOUBLE WALL A.TYPE OF ❑ _, P C;.. . , a E., ;,., :._ .. — SYSTEM ❑ 2 SINGLE WAIL ❑ 4 SINGLE,WALL INA VAULT ❑ 99 OTHER B. TANK ❑ ' ® EE- ❑ 2 STAINLESS STEEL r�S3 FIBERGLASS ❑ 4 STEEL CLAD,W/FIBERGLASS REINFORCED PLASTIC MATERIAL ® s CONCRETE ❑ 6 POLYVINYL CHLORIDE ® 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP (p"Tanq ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ® 99 OTHER 1 RUBBER LINED ® a ALKYD LINING ❑ 3 EPDXY LINING• 4 PHENOLIC ZJNING C.INTERIOR ❑ 1,� LINING OR ❑ s GLASS LINING (� UNLINED '` ! ® 95'UNNKNOW ® 99 OTHER COATING _ .. ...._ � IS LINING MATERIAL COMPATIBLE WITH 100x METHANOL Z ,*�,,YEIdo_ J •.:_, �.,�a<.: D.EXTERIOR M. T POLYERIYIENE WRAP ❑ 2 COATING�__" ❑ 3 VINYL WRAP: , � FIBERGLASS REINFORCED PLASnc CORROSION .,�.. ,,. „ ,s v,Rj t JVC 4 „M., ..:,t.�""....� PROTECTION ❑ S.CATHODIC PROTECTION ❑ 91 CNE A r . ,,,-_ C),951 UNKNOWN _.• ® 99 OTHER E.SPILL AND OVERFILL,6tC.!SPILL CONTAINMENT 1 ALLED(YEAR) - OVERFILL PWENTON EQUIPMENT INSTALLED(YEAR) : - DROP TUBE YES NO __ STRIKE PLATE YES -on NO ' DISPENSER CONTAINMENT YES G IV.PIPING INFORMATION— CIRCLE AIF ABOVE GROUND OR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 -SUCTION __A U 2 PRESSURE A U 3 GRAVITY A U 4-FLEXIBLE PIPING A U•99 OTHER'" B. CONSTRUCTION A U / SINGLE WALL , '''A U 2'DOUSLE 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)A U 4 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 6 CONCRETE " rz•....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 U ,99 OTHER D. LEAK DETECTION ❑1 OE OR E]a 3 xl�sllnu �aEcr�IN PIIS° ❑ sy 01,IER V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ ?• RECO CILIUAL ATTIION NTORY ❑ 3 VADOZEMONITORING ❑ 4 AUTOMATIC C TANK ® . MONITORINGOUND S ®® TESTING 7 MONITORING INTERSTITIAL ❑ 8 SIR ❑ a WEEKLY MANUAL❑10 MONTHLY TANK ❑ 95 UNKNOWN ❑99 OTHER VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-Pu10E) 1.ESTIMATED DATE LAST USED(MO/DAY/YR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH ,ES ❑ C❑ SUBSTANCE REMAINING GALLONS INERT MATERIAL 7 THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE GAND CORRECT (PRWKPE'DOi� ,TME)E DATE Lel -1 0 `� t�vA LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS C MPOSED OF THE FOUR NUMB14,8EL0 COUNTY 0 JURISDICTION 0 FACILI TANK 9 STATE LD:# C❑ F 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 f FILE THIS FORM WITH THE LOCAL AGENCY WLEM E D THERGROUND STORAGE TANK REGULATIONS FORM B (895)