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STATE OF CALIFORNIA �J 1 STATE WATER RESOURCES CONTROL BOARD " '" •'_c M1a UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B COMPLETE A SEPARATE f FORMFOREACH TANK SYSTEM.MARK ONLY ❑ 1 NEW PERMIT [:] 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ ] PERMANENTLY CL BED ON SITE l ONE REM ❑ 2 INTERIM PERMIT F76 AMENDED PERMIT 8 TEMPORARY TANK CLOSURE O 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.t B. MANUFACTURED BY: C. DATE INSTALLED(MO/DAYNEAR) D. TANK CAPACITY IN GALLONS: II.TANK CONTENTS IFA-1 IS MARKED,COMPLETE ITEM C. A �1 MOTOR VEHICLE FUEL ❑ d OIL B. C. 1a REGULAR UNLEADED 3 DIESEL ❑ 8 AVIATION GAS 2 PETROLEUM ❑ SO EMPTY' �1 PRODUCT ❑ 10 PREMIUM UMFADEO d GASAHOL ❑ T METHANOL ❑ is MIDGRADE UNLEADED 5 JETFUEL ❑ B M85 ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED 99 OTHER(DESCRIBE IN REM D.BELOWI 0. IF(At)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 UNEP ❑ 5 INTERNAL BLADDER SYSTEM ❑ 95 UNKNOWN SYSTEM ❑ 2 SINGLE WALL ❑ 4 SINGLE WALL IN A VAULT ❑ 99 OTHER B. TANK ❑ 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ a STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE 8 POLYVINYL CHLORIDE ❑ T ALUMINUM ❑ B 100% METHANOL COMPATIBLE WIFRP (PNm ry Tank) ❑ 9 BRONZE 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER C.INTERIOR ❑ I RUBBER UNED 2 ALKYD UNING ❑ 3 EPDXY UNING ❑ 6 PHENOLIC UNING LINING OR ❑ 5 GLASS UNING ❑ UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER COATING IS UNING MATERIAL COMPATIBLE WITH 1 METHANOL? VES_ NO— D.EXTERIOR ❑ 1 POLYETHYLENE WRAP ❑ 2 CO TING ❑ 3 VINYL WRAP ❑ d FIBERGLASS REINFORCED PLASTIC CORROSION PROTECTION ❑ 5 CATHODICPROTECTION ❑ 91 NO ❑95 UNKNOWN ❑ 99 OTHER E.SPILL AND OVERFILL,etc. 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 ORIF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U N FLEXIBLE PIPING A U 99 OTHER S. CONSTRUCTION A U 1 SINGLE WALL A U 2 DOUBLE WAL\ U 3 UNED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND A U I BARE STEEL A U 2 STAINLESS STE A U 3 POLYVINYL CHLORIDE(PVC)A U N FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U fi CONCRETE A U T STEEL W/COATING A U 8 100% METHANOL COMPATIBLE WIFRP PROTECTION A U 9 GALVANIZED STEEL A U /O CATHODIC PROTEC ON A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTIONM I IaaWae¢Ime LEN( 2 1.KE ncxm>:.ss 3 coxlwuaus BEcmaMc uuE s To .c'L. ❑ ❑ 9FIEmOB ❑ TESTING YONfOPAln ❑ DAK nE1E4TOR ❑ Swi00WN 99 OTHER V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 RECONCILIATIONNUAL INVENTORY ❑ 3 VADOZEMONITORING ❑ A AUTOMAnGAUGING C TANK ❑ 5 GROUND WATER ❑ 8 ANNUALTESTING ❑ T MONITORINGINTERSTITIAL ❑ 8 SIR ❑ 9 TAWEEKLY NEK LY MANUAL 10 MONTHLY TANK ❑ 95 UNKNOWN ❑ 99 OTHER G TESTING VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PUCE) i.ESTIMATED ATE LAST USED(MOAIAV/YFI? 2 ESTIMATED OUANRTY OF 3.WAS TANK FILLED WITH �$Li SUBSTANCE REMAINING ALLONS INERT MATERIAL? VES ❑ NO ❑ THIS F RM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE ST OF MY KNOWLEDGE,IS TRUE AND CORRECT TANK OWNER'S NAME DATE (PRINTED d SIGNANRET LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW D a 3 If cQ COUNTY 0 JURISDICTION# FACILITY k!'�,7 3 6.:1'�� TANK A STATE LD:# T-Fd O 4/ ! PERMIT NUMBER PERMIT APPROVED BVA]ATE PERMIT E%PIRATION DATE PERMIT NUMBER —TER 1 THIS FORM MUST BE ACCOMPANIED BY A PERMIT APP' ION-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. 'C MUST BE COMPLETED FOR INSTALLATIONS.THIS FORM SHOULD BE ACCOMPANIED BY A PLOT FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING n,, GROUND STORAGE TANK REGULATIONS FORM B (695) _! /_ Y