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STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD �0o UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B C�I.I OA M•' I. TANK DESCRIPTION COMPLETE ALL ITEMS – SPECIFY IF UNKNOWN A OWNER'S TANK I. D. # COMPLETE A SEPARATE FORM FOR EAC TANK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ON91TI ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE 8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: J j v I' }— l/;'j,(_ I. TANK DESCRIPTION COMPLETE ALL ITEMS – SPECIFY IF UNKNOWN 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.1 MOTOR VEHICLE FUEL ❑ 4 OIL B,C 1a REGULAR UNLEADED ❑ 3 DIESEL ❑ 6 AVIATIONGAS ❑ 1b PREMIUM UNLEADED ❑ 4 GASAHOL ❑ 7 METHANOL 2 PETROLEUM ❑ 80 EMPTY E�rl PRODUCT ❑ 1c MIDGRADE UNLEADED F—]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 LNER ❑ 5 INTERNAL BLADDER SYSTEM ❑ 95 UNKNOWN SYSTEM ❑ 2 SINGLE WALL ❑ 4 SINGLE WALL IN A VAULT ❑ 99 OTHER B TANK ❑ 1 BARE STEEL ❑ 2 STAINLESS STEEL E2r3 FIBERGLASS ❑ 4 STEEL CLAD W/ FIBERGLASS REINFORCED PLASTIC 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— D. EXTERIOR ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC CORROSION ❑ 5 CATHODIC PROTECTION �7,� �I gt NONE ❑ 95 UNKNOWN Ll99 OTHER PROTECTION I . E. SPILL AND OVERFILL, etc. SPILL CONTAINMENT IN TALLED (YEAR) OVERFILL Pa NTION EQUIPMENT INSTALLED (YEAR) 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 CORROSION PROTECTION A U A U A U 1 BARE STEEL 5 ALUMINUM 9 GALVANIZED STEEL A U A U A U 2 STAINLESS STEEL A U 6 CONCRETE A U 10 CATHODIC PROTECTION 3 POLYVINYL CHLORIDE (PVC)A U 4 FIBERGLASS PIPE 7 STEEL W/ COATING A U 8 100% METHANOL COMPATIBLE W/FRP A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION Ell MECHANICAL LINE LEAK ❑ DETECTOR 2 LINE TIGHTNESS ❑ 3 CONTINUOUS INTERSTmAL D 4 ELECTRONIC LINE O TESTING MONITORING LEAK DETECTOR 5 AUTOMATIC PUMPE7199 OTHER SHUTDOWN V. TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 RECONCILIATIONMANUAL INVENTORY E]3 MONIITORING ❑ VAOZE4 GAUGING AUTOMATIC TANK ❑ 5 MON TORINGGROUND WATER E:]6 TESTINGTANK ❑ 7 MONITORCONTINUOUS ❑ 8 SIR ❑ 9 TANK WEEKLY MANUAL F-110 MOTESTINGHLY TANK E:]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 ? 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) I r)rAl Ar:FNrV I ICF r1Nl V TNF CTATF I n NIIMRFR IS COMPOSED OF THE 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. THIS FORM SHOULD BE ACCOMPANIED BY A PLOT PI 9LE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE -RGROUND STORAGE TANK REGULATIONS FORM B (6.95) COUNTY # JURISDICTION # FACILITY # 31 TANK #005- DOSSTATE STATEI.D.# m 17= IA 13 11Iq Io s- o I f Iz„ Gia 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 PI 9LE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE -RGROUND STORAGE TANK REGULATIONS FORM B (6.95)