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STATE OFCAUFORNIASTATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM B o 1 ud� tiv I , COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. [MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT EDNE REM ❑ 2 INTERIM PERMIT ❑ ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLO EO ON ITE 4 AMENDED PERMIT 8 TEMPORARY TANK CLOSURE 8 TANK REMOVED OR FACILITY NAME WHERE TANK IS INSTALLED: / I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN ' A OWNER'S TANK I.D.4 B. MANUFACTURED BY: C. DATE INSTALLED(MO/DAYNEAR) ..... / D. TANK CAPACITY IN GALLONS: IL TANK CONTENTS IF A-1 1S MARKED,COMPLETE(ITEM C. A 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C to REGULAR UNLEADED ❑ 3 KIETF ❑ 8 AVIATION GAS /❑ 2 PETROLEUM ❑ 80 EMPTY �1 PRODUCT lb PREMIUM UNLEADED O 4 L ❑ 7 METHANOL ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ lc MKX;RADE UNLEADED 5 L ❑ 8 M85 2 LEADED 99ESCRIBE IN REM 0.BELONG D. IF(A1)IS NOT MAItED. ENTER NAME OF SUBSTANCE STORED C.A S.X III. TANK CONSTR TION MARK ONE ITEM ONLY IN BOXES A.B.AND C.AND ALL THAT APPLIES IN BOX D AND E A. TYPE OF F-1I UBLE WALL F-13 SINGLE WALL WITH EXTERIOR LINER ❑ 5 INTERNAL BUDDER SYSTEM ❑ 95 UNKNOWN SYSTEM ❑ 2 SI WALL ❑ 4 SINGLE WALL IN A VAULT ❑ 99 OTHER B. TANK ❑ iBARE EL F-12 STAINLESS STEEL E] 3 FIBERGLASS E] 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL F-15 CONCR ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ B 100% METHANOL COMPATIBLE W/FRP )Pfim9ry Tank) ❑ 9 BRONZE [-] 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER C.INTERIOR ❑ IRUBBER UNED F-12 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING LINING OR ❑ 5 GLASS UNING E] 8 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER COATING IS LINING MATERIAL COMPAT18 WITH 10D% METHANOL? YES_ NO— D.EXTERIOR ❑ 1 POLYETHYLENE WRAP 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC CORROSION PROTECTION ❑ 5 CATHODIC PROTECTION ❑ I NONE ❑95 UNKNOWN ❑ 99 OTHER E SPILL AND OVERFILL,lIC. SPILL CONTAINMENT INSTALLS EAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) DROP TUBE YES_ NO 3k STRIKER PLATE YES_ NO_ DISPENSER CONTAINMENT YES_ NO IV.PIPING INFORMATION CIRCLE A IF ABOVE GROU OR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION A U 2 PRES E A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION A U I SINGLE WALL A U 2 DOUBLE LL 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 EL A U 3 POLYVINYL CHLORIDE(PVC)A U 4 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 8 CONCRETE A U T STEEL W/COATING A U 8 100% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PRO TON A U 95 UNKNOWN A U 99 OTHER — D. YECXAMCN UNE LFAN 2 INE TMHTM:55 3 CgRIN6WS d EIECIRONIC UNE 5 A.O, TC PUIN 99 OTHER D. LEAK DETECTION ❑ aLTEcron ❑ TE9TNc ❑ WMTCRINO ❑ LE4N DET=R sNuroovm ❑ V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 RECONCILIATIONORY ❑ 3 VADOZE MONITORING 4 AUTOGAUGING C TANK ❑5 MONITORINGOUND TER ❑ 8 TE�NGTANK ❑ 7 MN NUOU INTERSTITIAL ❑ 8 SIR ❑ 9 TWEEKLY ANKGAUGINGAL 10 MONTHLY TANK ❑ 95 UNKNOWN ❑99 OTHER VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) 1.ESTI A TE LAST USED(MO/DAY/YR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES ❑ NO SUBSTANCE REMAINING GALLONS INERT MATERIAL 7 THIS ORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT TANK OWNER'S NAME DATE (PRINTW A SIGNATURE) y— LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW 2et... I COUNTY! JURISDICTION A FACILITY A TANK k STATE I.D.# m = 771 -� 1106d PERMIT NUMBER PERMIT APPROVED BYADATE 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" -ILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE U'--9GROUND STORAGE TANK RREG�U(,/UTMNS � FORM B (6-95) 1 ?/v 5- 74, QL 'f/'rJ