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STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD sy t�O UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B ° COMPLETE A SEPARATE FORMFOREACH TANK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ON QITE ONE REM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT �`❑ 6 TEMPORARY TANK CLOSURE ❑ B TANK REMOVED G DBA OR FACILITY NAME WHERE TANK IS INSTALLED: 7,42 J I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A OWNERS TANK I.D.# B. MANUFACTURED BY: C. DATE INSTALLED(MO/DAY/YEAR) 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. ID 1S REGULAR UNLEADED 3 DIESEL ❑ 6 AVIATION GAS 2 PETROLEUM ❑ 80 EMPTY 1 PRODUCT ❑ 1b PREMMM UNLEADED 4 GASAHOL ❑ 7 METHANOL ❑ 1C MIDGRADE UNLEADED ❑ 5 JET FUEL ❑ B M85 ❑ 3 CHEMICALPRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED ❑ 99 OTHER(DESCRIBE IN ITEM D.BELOM D. IF(Al)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S.M: III. TANK CONSTRUCTION M K 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 LINER ❑ 5 INTERNAL BLADDER SYSTEM ❑ 95 UNKNOWN SYSTEM ❑ 2 SINGLE WALL ❑ 4 SINGLE WALL IN A VAULT ❑ 99 OTHER B. TANK ❑ 1 BARE STEED- VEJ 2 STAINLESS STEEL ❑ 3 FIBERGLASS E:] 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ B 100% METHANOL COMPATIBLE W/FRP (POMWY Too) ❑ 9 BRONZE 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER C.INTERIOR ❑ 1 RUBBER LINED 2 ALKYD LINING r-13 EPDXY LINING ❑ 4 PHENOLIC LINING LINING OR ❑ 5 GLASS LINING 6 UNLINED F-195 UNKNOWN ❑ 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WI 100% METHANOL? YES_ NO— D.EXTERIOR ❑ 1 POLYETHYLENE WRAP ❑ 2 ATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC CORROSION PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 N E ❑ 95 UNKNOWN ❑ 99 OTHER E.SPILL AND OVERFILL,6M. 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 O U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION A U 2 PRESSU A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION A U I SINGLE WALL A U 2 DOUBLE W A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND A U 1 BARE STEEL A U2 STAINLESS S L A U 3 POLYVINYL CHLORIDE(PVC)A U 4 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 8 CONCRETEA U 7 STEEL W/COATING A U 8 700% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PRO ON A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION ❑1 KECNAMCAL UNE LEN( 2 UNE TGKIN966 3 CCNTINUW6 1 URAL 4 EIECI90NIC UNE 5 A9TCMATIC MW 9EIEMOR TESM3 ❑ IwNTG ❑ UAK()ETEIOR ❑ 6Nt l l E] e9 OTHER V.TANK LEAK DETECTION ❑ 7 VISUAL CHECK ❑ 2 RRECONCILIATIONUAL ORY ❑ 3 VADOZE MONITORING 4 AUTOMKTIGAUG NG C TANK ❑5 MOONITORINGROUND WATER ❑ 6 TESTING ❑ 7 MONITORING INTERSTITIAL ❑ B SIR ❑ 9 TANK LY MANUAL 10 TESTING TANK ❑ 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PUCE) 1.ESTIDTE LAST USED(MO)DAYNR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES EDNO❑ SUBSTANCE REMAINING IN LONS INERT MATERIAL 7 THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BE OF MY KNOWLEDGE,IS TRUE AND CORRECT TANK OWNER'S NAME DATE (PRW &SIGNATURE) LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY# TANK# STATE I.D.4 m 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 PLA" 9LE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UA"+iGROUND STORAGE TTTTTANK REGULA FORM B (6-95) `w ��11 -6 ��