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STATE OF CALIFORNIA 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 ZIP" CHANGE OF INFORMATION ONE ITEM 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE DBA OR FACILITY NAME WHERE TANK IS INSTALLED: I. TANK DESCRIPTION COMPLETE ALL ITEMS - SPECIFY IF UNKNOWN ❑ 7 PERMANENTLY CLOSED Q,QI-4alTE TANK REMOVED A. OWNER'S TANK I. D. 0 1 B. MANUFACTURED BY: UNKNOWN C. DATE INSTALLED (MO/DAYNEAR) UNKNOWN I D. TANK CAPACITY IN GALLONS: 81000 II- TANK CONTENTS IF A-1 IS MARKED. COMPLETE ITEM C. A. �j 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C. to REGULAR UNLEADED ❑ 3 DIESEL ❑ 6 AVIATION GAS ❑ 2 PETROLEUM ❑ 80 EMPTY IX�] t PRODUCT lb PREMIUM UNLEADED ❑ 4 GASAHOL ❑ 7 METHANOL ❑ is MIDGRADE UNLEADED ❑ 5 JET FUEL ❑ 8 M85 ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED El 99 OTHER (DESCRIBE IN ITEM 0. BELOW) D. IF (A.1) IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C. A. S. N: III TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A. B, AND C, AND ALL THAT APPLIES IN BOX D AND E IV PIPINr. INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND, BOTH IF APPLICABLE A. SYSTEM TYPE ❑ 1 DOUBLE WALL F7 3 SINGLE WALL WITH EXTERIOR LINER ❑ 5 INTERNAL BLADDER SYSTEM ❑ 95 UNKNOWN A. TYPE OF SYSTEM X❑ 2 SINGLE WALL ❑ 4 SINGLE WALL IN A VAULT ❑ 99 OTHER A U X❑ 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 A U ❑ 1 RUBBER UNED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING C. INTERIOR LINING OR fll� 5 GLASS LINING ❑ 6 UNLINED ❑ 95 UNKNOWN I�{99 OTHER FRP AND STYRENE COATING IS LINING MATERIAL COMPATIBLE WITH 100'/6 METHANOL? YES _ NO_ 1MECHANICAL UNE LEAK 0 D. EXTERIOR F7 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC CORROSION ❑ 5 CATHODIC PROTECTION I❑ 91 NONE IZI95 UNKNOWN ❑ 99 OTHER PROTECTION SPILL CONTAINMENT INSTALLED (YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED (YEAR) E. SPILL AND OVERFILL, etc. DROP TUBE YES NO STRIKER PLATE YES NO DISPENSER CONTAINMENT YES NO IV PIPINr. INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND, BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION ACU 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 <D5 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 1007 METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION AUO95 UNKNOWN A U 99 OTHER D. LEAK DETECTION 1MECHANICAL UNE LEAK 0 ITIAL4 ELECTRONIC UNE ❑ 5 AUTOMATIC PUMP 99 OTHER ❑ SHUTDOWN ❑ oETECTDR TETESTING❑ 40NITORING LEAK DETECTOR V. TANK LEAK DETECTION J 1 VISUAL CHECK El MANUAL INVENTRECONCILIATIONORY ❑ 3 MONITORING l K VADOZE4 GAUG NGAUTOMATIC TANK ❑ 5 MONITORINGGROUND ❑ b TESTING ❑ 7 MON TOROUS INTERSTITIAL ❑ 8 SIR El9 WEEK LY MANUAL ❑ 10 MO THLY TANK ❑ 95 UNKNOWN ❑ 99 OTHER VI. TANK CLOSURE INFORMATION (PERMANENT CLOSURE IN-PLACE) 1. ESTIMATED DATE LAST USED (MOiOAY/YR) 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 A N f4M S�NIa� O�r,,, �j d e0 DATE (PRINTED 8 SIGNATURE) /�-7G(T 9 3 I rlrs A I A rCAIPV I ICC r1All V Tuc crATC I In unuact] IC Cr1MPr1C;:n TIF THF P01IR NI IMRFRS RELOW COUNTY # JURISDICTION # FACILITY # i TANK # D STATE I.D.n m ��q' � 0 I PERMIT NUMBER PERMIT APPeOVED BYIDATE j 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 Ot 'ILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE' 'RGROUND STORAGE TANK REGULATIONS FORME (6-95) 2.11 4l