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•CGS STATE OF CALIFORNIA 2 STATE WATER RESOURCES CONTROL BOARD sy UNDERGROUND STORAGE TANK PERMIT -APPLICATION - FORM B " o COMPLETE A SEPARATE FORM FOR CH TANK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION❑ 7 P ANENTLY CLOSE _ ON SITE ONE ITEM `❑ 2 INTERIM PERMIT ❑I a AMENDED PERMIT 6 TEMPORARY TANK CLOSURE 6 TANK REMOVED v / DBA OR FACILITY NAME WHERE TANK IS INSTALLED:' I. TANK DESCRIPTION COMPLETE ALL ITEMS - SPECIFY IF UNKNOWN A OWNER'S TANK I. D. # 3 B. MANUFACTURED BY: UNKNOWN C. DATE INSTALLED (MO/DAYNEAR) L�� PRODUCT D. TANK CAPACITY IN GALLONS: r II. TANK CONTENTS IF A-1 IS MARKED, COMPLETE ITEM C. A n/ 1 MOTOR VEHICLE FUEL C❑ 4 OIL B. C ❑] REGULAR UNLEADED ❑ 3 DIESEL ❑ 6 AVIATION GAS Dl(` -_LTJ 2 PETROLEUM F7PREMIUM BO EMPTY L�� PRODUCT .1 La Ute' UNLEADED E:]4 GASAHOL ❑ 7 METHANOL ❑ is MIDGRADE UNLEADED ❑ 5 JET FUEL ❑ B M85 ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED ❑ 99 OTHER (DESCRIBE IN ITEM D. BELOM 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 UNER ❑ 5 INTERNAL BLADDER SYSTEM ❑ 95 UNKNOWN SYSTEM 2 SINGLE WALL F74 SINGLE WALL IN A VAULT El 99 OTHER B. TANK /--'t 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 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 F7❑ 2 ALKYD LINING 3 EPDXY UNING 4 PHENOLIC LINING LINING OR F75 GLASS LINING ❑ 6 UNUNED ❑ 95 UNKNOWN oo !� ER, 99 OTHER ��11-U�� COATING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO— A U 99 OTHER D. EXTERIOR ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑� 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC CORROSION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE �TII��yy �95 UNKNOWN ❑ 99 OTHER PROTECTION LEAK DETECTOR TD SHUTDOWN E. SPILL AND OVERFILL, BIC. SPILL CONTAINMENT INSTALLED (YEAR) OVERFILL PREVENTION 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(gt PRESSURE A U 3 GRAVITY A U A 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 5 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 5 UNKNOWN A U 99 OTHER D. LEAK DETECTION 1 MECHANICAL LINE LEAK [g 2 UNE TIGHTNESS ❑ 3 CONTINUOUS INTERST LkL [:]4 ELECTRONIC LINE 7]5 AUTOMATIC PUMP ❑ 99 OTHER CTOR TESTING MONITORING LEAK DETECTOR TD SHUTDOWN V. TANK LEAK DETECTION ❑NUAL 1 VISUAL CHECK ❑ 2 RECO CILIATIONMANUAL INVENTORY ❑ 3 MONITORING � VADOZE4 GAUGING AUTOMATIC TANK L75 MONITORING GROUND WATER ❑ 6 TEESTINGTANK ❑ 7 MON TORIOU INTERSTITIAL ❑ 6 SIR ❑ 9 WEEK LY MANUAL ❑ 10 MONTHLY TANK ❑ 95 UNKNOWN El 99 OTHER VI. TANK CLOSURE INFORMATION (PERMANENT CLOSURE IN-PLACE) 1. ESTIMATED DATE LAST USED (MO/DAY/YR) 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 (PRINTED DATE TANK OWNER'S A SIGNATURE) E SA NAM SAN C'/ . Da�+f 7 -OOP, LOCAL AGENCY USE ONLY THE STATE I.D. NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY # JURISDICTION # FACILITY # L+ TANK # STATE I. D.# ❑ i D �� ^, PERMIT NUMBER PERMIT APPROVED BYIDATE PERMIT EXPIRATION DATE �j _ /A THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPI )N - FORM A, UNLESS A CURRENT FORM A HAS BEEN FILED. C MUST BE COMPLETED FOR INSTALLATIONS. THIS FORM SHOULD BE ACCOMPANIED BY A PLOT 1 -ILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING TH 9GROUND STORAGE TANK REGULATIONS q,0 1 FORMS (6-95) �IO 111191// ��(P11