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tbOU�CCJ STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B C�1,I011 H.� COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. i MARK ONLY ❑( 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ON SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: I. TANK DESCRIPTION COMPLETE ALL ITEMS - SPECIFY IF UNKNOWN A OWNER'S TANK I. D. # B. MANUFACTURED BY: v C. DATE INSTALLED (MO/DAYNEAR) D. TANK CAPACITY IN GALLONS: j oo too II. TANK CONTENTS IF A-1 IS MARKED, COMPLETE ITEM C. A. Z1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C ❑ REGULAR UNLEADED ❑ 3 DIESEL ❑ 6 AVIATION GAS F-]2 PETROLEUM ❑ 80 EMPTY � PRODUCT t 1b PREMIUM UNLEADED ❑ 4 GASAHOL ❑ 7 METHANOL F-1lcMIDGRADE UNLEADED ❑ 5 JET FUEL E]8 M85 El 3 CHEMICAL PRODUCT El 95 UNKNOWN El 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 02,111 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. TANK EO"l 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 A U 6 CONCRETE ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING C. INTERIOR LINING OR ❑ 5 GLASS LINING ❑ 6 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 1001/6 METHANOL? YES— NO— 2 LINE TIGHTNESS 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 E. SPILL AND OVERFILL, CtC. SPILL CONTAINMENT INSTALLED (YEAR) OVERFILL P VENTION 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 2 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL A C) 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 B 100% METHANOL C MPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER I l M_- D. LEAK DETECTION ECHAMCAL LINE LEAK ❑ 2 LINE TIGHTNESS CONTINUOUS INTERSTITIAL 4 ELECTRONIC UNE ❑ AUTOMATIC PUMP 99 OTHER ❑ DETECTOR TESTING MONITORING LEAK DETECTOR SHUTDOWN V TANK I FAK nFTFCTION ��❑ 11 VISUAL CHECK El RECONCILIATIONMANUAL INVENTORY ❑ 3 MONITORING 4 GAUG NAAUTOMG IC TANK ❑ 5 MON TORINGGROUND WATER ❑ 6 TESTIINGTANK ' 7 MONITORING INTERSTITIAL [:]8 SIR ❑ 9 EEK LY MANUAL ❑ 10 MONTHLY TANK ❑ 95 UNKNOWN ❑ 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 I 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) 1 OrAI ArFNry I IRF ONI V Tw: sTATF I n Nt1MRFR IS COMPOSED OF THE FOUR NUMBERS BELOW ---.._ .._-•--• --- -.._. ...---------------- COUNTY # JURISDICTION # FACILITY # OD3/(p TANK # OS' STATE I.D:# 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 PLAN. FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATION��S�� ,// � FORM B (6.95) q(ila i7.