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i • STATE OF CAUFORNIA STATE WATER RESOURCES CONTROL BOARD :yds UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B > , Id; . COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. c• --, rt 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 ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED , S/ DBA OR FACILITY NAME WHERE TANK IS INSTALLED: //--U I. TANK DESCRIPTION COMPLETE ALL ITEMS– SPECIFY IF UNKNOWN A OWNER'S TANK I.D.♦ B. MANUFACTURED BY: �� :_I�.^�• M AWYEAR 1 ' D. TANK CAPACITY IN GALLONS �-� C. DATE INSTALLED( O/D ) /i ;/f:�,-_�.)�.'� � uU II.TANK CONTENTS IF A-1 IS MARKED,COMPLETE ITEM C. ❑ to REGULAR UNLEADED DIESEL ❑ 8 AVIATION GAS A Q b MOTOR VEHICLE FUEL ❑ OIL B. w+ C ❑ 10 PREMIUM UNLEADED 4 GASAHOL ❑ 7 METHANOL ❑ 2 PETROLEUM ❑ 80 EMPTY ISL 1 PRODUCT 4 ❑ 1c MIDGPADE UNLEADED ❑ 5 JETFUEL ❑ B MBS ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN 7❑� 2 WASTE ❑ 2 LEADED ❑ 99 OTHER(DESCRIBE IN REM D.BELOW) D. IF(A.1)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 0 AND E I DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 5 INTERNAL BLADDER SYSTEM ❑ 95 UNKNOWN A. TYPE OF ❑ SYSTEM 2 SINGLE WALL ❑ 4 SINGLE WALL IN A VAULT 99 OTHER ❑ 1 BARE STEEL ❑ 2 STAINLESS STEEL 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B. TANK MATERIAL F—] 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING C.INTERIOR �,/'� LINING OR ❑ 5 GLASS LINING I\/I�8 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER COATING IS LINING MATERIAL COMPATIBLE ITH 10(r. METHANOL YES_ NO_ D.EXTERIOR ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING El 'J4 3 VINYL WRAP LJ FIBERGLASS REINFORCED PLASTIC CORROSION 91 NONE ❑95 UNKNOWN 99 OTHER PROTECTION ❑ 5 CATHODIC PROTECTION ❑ SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EOUIPMENTINSTALLED(YEAR) E.SPILL AND OVERFILL,BIC. DROP TUBE YES__ NO_ STRIKER PLATE YES_ NO__ DISPENSER CONTAINMENT VES-- NO IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND.BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL 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) FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U B CONCRETE A U 7 STEEL W/COATING A U B 100% METHANOL COMPATIBLE W/FflP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER 1 MECHANICAL UNE LEAK2 LINE TIGMNESS ❑3 COMM?0uS INrER!iM4 ❑4 ELECLaONIC UNE 0 5 AVOI ARC NMR ❑ 99 OTHEA D. LEAK DETECTION oETEcrca ❑ TEsmm MONTORM LEAK oElEcroa slMrcowN V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 MANUAL INVENTORY ❑ 3 MONOITORING ❑ 4 GAUGINGTIC TANK ❑5 MONITORINGTER ❑8 TESTINGTANK 1� RECONCILIATION IJ 7 MONITOR NG INTERSTITIAL ❑ 8 SIR ❑ 9 TAENKGAUGINGMANUAL ❑ 10 TESTING TANK ❑ 95 UNKNOWN 99 OTHER VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) 3.WAS TANK FILLED WITH YES E] NO 1.ESTIMATED DATE LAST USED(MOIDAYNR) 2.ESTIMATED QUANTITY OF ❑ SUBSTANCE REMAINING GALLONS( INERT MATERIAL THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT DATE TANK OWNER'S NAME (PRINTED A SIGNATURE) LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY N JURISDICTION k FACILITY# el TANK k 0 aLF STATE I.D:# m 3 1 PERMIT NUMBER PERMIT APPROVED BYIDATE PERMIT EXPIRATION DATE 1 13 y THIS FC.RM MUST BE ACCOMPANIED BY A PERMIT APPUCyyyTTT��QQQN-FORM A,UNLESS ACURRENT FORM A HAS BEEN FILED. FOR Q MG TANKROUND STORAGE NK REGULATIONSNS THIS FORM SHOULD BE ACCOMPANIED BY A PLOT E THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING TH�!` FORM B 16-95)