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. ^lspvnt.'i C STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD u n v UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. B. MANUFACTURED BY: t FI`1 D. TANK CAPACITY IN GALLONS: fit' UIfIl'-" L" A. TYPE OF SYSTEM ❑ 2 SINGLE WALL . I MARK ONLY ��III 1 NEW PERMIT bl ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 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:j r� c y/ ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL I TANK nFsrRIPTION COMPLETE ALL ITEMS - SPECIFY IF UNKNOWN A. OWNER'S TANK I. D. # B. MANUFACTURED BY: C. DATE INSTALLED (MO/DAY/YEAR) 7 % � D. TANK CAPACITY IN GALLONS: fit' UIfIl'-" L" II TANK rnNTFNT9 IF A-1 IS MARKED COMPLETE ITEM C. A. I MOTOR VEHICLE FUEL ❑ 4 OIL a 2 PETROLEUM ❑ 80 EMPTY ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN B.C. PRODUCT x ❑ 2 WASTE to REGULAR UNLEADED ❑ 3 DIESEL ❑ 6 AVIATION GAS ❑ 1b PREMIUM UNLEADED ❑ 4 GASAHOL ❑ 7 METHANOL ❑ 1c MIDGRADE UNLEADED ❑ 5 JET FUEL ❑ 8 M85 ❑ 2 LEADED ❑ 99 OTHER (DESCRIBE IN ITEM 0. BELOW) D. IF (A.1) IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C. A. S. #: 111 TANK rnNSTRI IrTION MARK ON1F ITEM ONLY IN BOXES A. B. AND C. AND ALL THAT APPLIES IN BOX D AND E Ill DIDIAIr: INPnAUATInN r,arl c A IF ARnVF nFInIIND OR U IF UNDERGROUND. BOTH IF APPLICABLE A. SYSTEM TYPE p 1 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 A 4)2 DOUBLE WALL ❑ 1 BARE STEEL ❑ 2 STAINLESS STEEL 3 FIBERGLASS ❑ 4 STEEL CLAD W/ FIBERGLASS REINFORCED PLASTIC B. TANK MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM 8 100% METHANOL COMPATIBLE W/FRP (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER PROTECTION ❑ I RUBBER LINED O 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING C. INTERIOR LINING OR kn 5 GLASS LINING ❑ 6 UNLINED❑ 5 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 ❑ 5 CATHODIC PROTECTION ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER PROTECTION SPILL CONTAINMENT INSTALLED (YEAR)[_[_ OVERFILL PREVENTION EQUIPMENT INSTALLED (YEAR) E. SPILL AND OVERFILL, @tC. DROP TUBE YES NO STRIKER LATE YES NO DISPENSER CONTAINMENT YES NO Ill DIDIAIr: INPnAUATInN r,arl c A IF ARnVF nFInIIND OR U IF UNDERGROUND. BOTH IF APPLICABLE A. SYSTEM TYPE A �7 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL A 4)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 U 3 POLYVINYL CHLORIDE (PVC)A04 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEELW/COATING A U 8 100% METHANOL COMPATIBLEW/FRP PROTECTION A 6)9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION 1 MECHANICAL UNE LEAK 1:12 DETECTOR LINE TIGHTNESS ® 3 CONTINUOUS INTERSTITIAL ❑ 4 ELECTRONIC LINE ❑ TESTING MONITORING LEAK DETECTOR 5 AUTOMATIC PUMP O 99 OTHER SHUTDOWN V. TANK LEAK DETECTION F-1 1 VISUAL CHECK ID RECONCILIATION RECONCILIATIONORY ❑ 3 MONIITORING VAOZE ❑ 4 AUTOMATGAUGING IC TANK ❑ 5 GROUND MON TORINGTER ❑ 6 TAENSTINGTANK MANUAL 7 CONTINUS MONITORU INTERSTITIAL ❑ 8 SIR ❑ 9 WENK LY MANUAL [:]10 MONTESTTHLY TANK ❑ 95 UNKNOWN ❑ 99 OTHER VI. TANK CLOSURE INFORMATION (PERMANENT CLOSURE IN-PLACE) 1. ESTIMATED DATE LAST USED (MO/DAYNR) 2. ESTIMATED QUANTITY OF 3. WAS TANK FILLED WITH YES ❑ NO ❑ SUBSTANCE REMAINING GALLONS INERT MATERIAL 7 TNI.s FnRM HA.S PFFN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, 1S TRUE AND CORRECT TANK OWNER'S NAME � �- // DATE (PRINITEDBSIGNATURE) �//�/r nrA 1 ArrCnlrrV I ICD nKII V TUG QTAT>= I n NUMBER IS COMPOSFn OF THF FOUR NUMBERS BELOW 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. I ms runts SHOULD BE ACCOMPANIED BY A PLOT PLAN. FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS FORM 8 (6-95) COUNTY # JURISDICTION # FACILITY # TANK # STATE I.D.# 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. I ms runts SHOULD BE ACCOMPANIED BY A PLOT PLAN. FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS FORM 8 (6-95)