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v STATE OF CALIFORNIA `' ••+ o�� STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B 1 COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. O ❑ 7 PERMANENTLY CLOSED ON SITE MARK ONLY ❑ 1 NEW PERMIT 3 RENEWAL PERMIT J� 5 CHANGE OF INFORMATION ONE REM ❑ 2 INTERIM PERMIT ❑ 0 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED OBA OR FACILITY NAME WHERE TANK IS INSTALLED: I. TANK DESCRIPTION COMPLETE ALL ITEMS— SPECIFY IF UNKNOWN B. MANUFACTURED BY: A OWNER'S TANK 1.D.# III C. DATE INSTALLED(MO/DAY/YEAR) D. TANK CAPACITY IN GALLONS: II.TANK CONTENTS IFA-1 IS MARKED,COMPLETE ITEM C. 1a REGUUR UNLEADED 3 DIESEL ❑ 8 AVIATION GAS A 1 MOTOR VEHICLE FUEL O < OIL B. C. ❑ 1C PREMIUM UNLEADED 4 GASAHOL ❑ 7 METHANOL 2 PETROLEUM ❑ 80 EMPTY PRODUCT ❑ 1c MK%iRADE UNLEADED O 5 JET FUEL ❑ 8 M85 3 CHEMICAL-PRODUCT ❑ BS UNKNOWN ❑ 2 WASTE ❑ 2 LEADED ❑ 99 OTHER(DESCRIBENffEM D.BELOWI D. IF(A1)IS NOT MARKED, ENTER NAME OF SUSSTACE STORED C.A.S.N III. TANK CONSTRUCTION MAR ONE ITEM ONLY IN BOXES A.B,AND C.AND ALL THAT APPLIES IN BOX D AND E A. TYPE OF ❑ 1 DOUBLE WALL F-1 3 SINGLE WALL WITH EXTERIOR LINER ❑ 5 INTERNAL BLADDER SYSTEM ❑ 95 UNKNOWN SYSTEM ❑ 2 SINGLE WALL ❑ < SINGLE WALL IN A VAULT ❑ 89 OTHER B. TANK ❑ 1 BARE STEEL O 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ < STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE 8 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ B 100% METHANOL COMPATIBLE W/FRP IPN9rTa"W ❑ 9 BRONZE 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER C.INTERIOR ❑ 1 RUBBER LINED 2 ALKYD LINING ❑ 3 EPDXY LINING 4 PHENOUC LINING LINING OR ❑ 5 GLASS LINING ❑ UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 1 METHANOL? YES_ NO_ D.EXTERIOR ❑ 1 POLYETHYLENE WRAP ❑ 2 CO TING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC CORROSION PROTECTION ❑ 5 CATHODIC PR OTECTON ❑ 91 NO ❑ 95 UNKCWN ❑ 99 OTHER SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) E.SPILL AND OVERFILL,9SC. DROP TUBE YES NO_ STRIKER PLATE YES_ NO_ DISPENSER CONTAINMENT YES_ NO_ IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND ORNYIF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION A U 2 PRESSUR A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL A U 2 DOUBLE WA 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 S A U 3 POLYVINYL CHLORIDE(PI U 4 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 8 CONCRETE A U 7 STEEL W/COATING A U 8 100% METHANOL COMPATIBLE WIFRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODICPROTE ON A U 95 UNKNOWN A U 99 OTHER D, LEAK DETECTION ❑t NEGN4NGLL uxE vAK 2 uxE nGxrxEss ❑3 coxn,,N, %s ❑4 B.EcmaMc UK ❑5 AVONA00 NW ❑ 99 OTHER oErEaoR M nxG 9omronlxa LPAK of UM 9AR m V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 RECONCILIATIONNUAL ORY ❑ 3 MONITORING ❑ 4 AUTOMATGAUGING MONITORING TANK ❑5 GROUND MONTORING�R ❑ 8 ANNUTESTING ❑ 7 COTINUOUS MONITORINGINTERSTITIAL ❑ 8 SIR ❑ 9 TWEEKLY ANKGAUGINGAL 10 TESTINGY TANK O 95 UNKNOWN ❑99 OTHER VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) 1.ESTIMATED ATE LAST USED(MO/DAYNR) 2 ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES SUBSTANCE REMAINING GALLONS INERT MATERIAL 7 [:] G ❑ THIS F RM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE kST OF MY KNOWLEDGE, IS TRUE AND CORRECT TANK OWNER'S NAME DATE (PRINTED A 910NATURE) LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW _{ ;43 ( 96- 0 COUNTY* JURISDICTION k FACILITY M TANK�# STATE 04 m = = 1116910 010 PERMIT NUMBER PERMIT APPROVED BV/DATE PERMIT EXPIRATION DATE THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORMA HAS BEEN FILED. FORM C MUST BE COMPLETED FOR INSTALLATIONS. THIS FORM SHOULD BE ACCOMPANIED BY A PLOT PLAN II THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UVAI.iGROUND STORAGE TANK REGULATIONS FORMS (6-95) �. // 5— 9{_ /A u(//B