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STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD u moo UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B .e o COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ON ITI ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT_ ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED q DBA OR FACILITY NAME WHERE TANK IS INSTALLED: / ❑ 4 STEEL CLAD W/ FIBERGLASS REINFORCED PLASTIC B TANK 3 LINED TRENCH A U I. TANK DESCRIPTION COMPLETE ALL ITEMS – SPECIFY IF UNKNOWN I A OWNER'S TANK I. D. # B. MANUFACTURED BY: C. DATE INSTALLED (MO/DAYNEAR) D. TANK CAPACITY IN GALLONS: II. TANK CONTENTS IF A-1 IS MARKED, COMPLETE ITEM C. A. t MOTOR VEHICLE FUEL ❑ 4 OIL B. C ❑ REGULAR UNLEADED ❑ 3 DIESEL ❑ 6 AVIATION GAS ❑� 2 PETROLEUM E:]80 EMPTY [2 1 PRODUCT 1b PREMIUM UNLEADED ❑ 4 GASAHOL ❑ 7 METHANOL ❑ 1c MIDGRADE UNLEADED ❑ 5 JET FUEL ❑ 8 M85 ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED ❑ 99 OTHER (DESCRIBE IN ITEM D. BELOW) D. IF (A.1) IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C. A. S. #: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A, B, AND C, AND ALL THAT APPLIES IN BOX D AND E A. TYPE OF ` 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 5 INTERNAL BLADDER SYSTEM ❑ 95 UNKNOWN SYSTEM ❑ 2 SINGLE WALL ❑ 4 SINGLE WALL IN A VAULT ❑ 99 OTHER B. CONSTRUCTION ❑ 1 BARE STEEL ❑ 2 STAINLESS STEEL ff3 FIBERGLASS ❑ 4 STEEL CLAD W/ FIBERGLASS REINFORCED PLASTIC B TANK 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND A U 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 C. INTERIOR ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING LINING OR ❑ 5 GLASS LINING ❑ 6 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES — NO— 2 LINE TIGHTNESS ❑ 3 CONTINUOUS 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, CtC. 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 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 U 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) A U 4 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 6 CONCRETE 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 MECHANICAL LINE LEAK ❑ 2 LINE TIGHTNESS ❑ 3 CONTINUOUS INTERSTITIAL ❑ 4 ELECTRONIC UNE ❑ 5 AUTOMATIC PUMP ❑ 99 OTHER DETECTOR TESTING MONITORING LEAK DETECTOR SHUTDOWN V. TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 MANUAL RECONCILIATIONORY ❑ 3 VAOZE MONIITORING ❑ 4 AUTOMATGAUGING IC TANK ❑ 5 GROUND MONITORING TER ❑ 6 TETANK STING ❑ 7 MONITORING INTERSTITIAL E]8 SIR ❑ 9 WEEK LY MAN ❑ UAL 10 MONTHLY TANK ❑ 95 UNKNOWN ❑ 99 OTHERTES VI. TANK CLOSURE INFORMATION (PERMANENT CLOSURE IN-PLACE) 1. ESTIMATED DATE LAST USED (MO/DAYNA) 2. ESTIMATED QUANTITY OF 3. WAS TANK FILLED WITH YES ❑ NO ❑ SUBSTANCE REMAINING GALLONS INERT MATERIAL 7 THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT TANK OWNER'S NAME DATE (PRINTED 8 SIGNATURE) nrAl erFNrV I ICF ONI V TNF CTeTE I n_ NIIMRER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY # JURISDICTION # FACILITY #3 TANK # Q STATE I.D:# m 3 I LI c s S Q yJ y 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 I FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING TH- `ERGROUND STORAGE TANK REGULATIONS FORMS (6-95)