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STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD o UNDERGROUND STORAGE TANK PERMIT APPLICATION -FORM B COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. SII MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED I OBA OR FACILITY NAME WHERE TANK IS INSTALLED: , I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A OWNERS TANK I.D.R B. MANUFACTURED BY: C. DATE INSTALLED(MO/DAYIYEAR) 0. TANK CAPACTTY IN GALLONS: QV II.TANK CONTENTS IFA-1 IS MARKED,COMPLETE ITEM C. A. 1 MOTOR VEHICLE EL ❑ 4 OIL B. C. ❑ le REGULAR UNLEADED Q 3 DIESEL ❑ B AVIATION GAS ❑ 2 PETROLEUM ❑ 80 EMPTY 1 PRODUCT lb PREMUM UNLEADED ❑ 4 GASAHOL ❑ 7 METHANOL ❑ It MOGRADE UNLEADED 5 JET FUEL ❑ 8 M85 ❑ 3 CHEMICAL PROD1 ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 cnnm g 99 07HER(M RIBENREMDBELOM 0. IF(A1)IS NOT MARKED, ENTEk NAME OF SUBSTANCE STORED C.A S R: 111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.S.AND C,AND ALL THAT APPLIES IN BOX 0 AND E A. TYPE OF ❑ 1 DOUBLEALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 5 INTERNAL BLADDER SYSTEM ❑ 95 UNKNOWN SYSTEM ❑ 2 SINGLE W ❑ 4 SINGLE WALL IN A VAULT ❑ 99 OTHER B. TANK ❑ 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CIAO W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ B 100% METHANOL COMPATIBLE W/FRP (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER C.INTERIOR ❑ 1 RUBBER LINED ❑ 2 ALKYD UNING ❑ 3 EPDXY LINING ❑ 4 PHENOUC LINING LINING OR ❑ 5 GLASS LINING ❑ 8 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER COATING IS LINING MATERIAL COMPO BLE WITH 100% METHANOL? YES_ NO— D.EXTERIOR ❑ 1 POLYETHYLENE ❑ 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC CORROSION PROTECTION ❑ 5 CATHODIC PROTECTION 91 NONE ❑95 UNKNOWN ❑ 99 OTHER E SPILL AND OVERFILL,8L0. SMLLCONTAINMENTIN ALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLEn(YEAR) DROP TUBE VES NO_ STRIKER PLATE YES_ NO_ DISPENSER CONTAINMENT VES_ NO IV.PIPING INFORMATION CIRCLE A IFA VE GROUND OR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL A k ZDOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND A U 1 BARE STEEL A U2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A U 4 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U CONCRETE A U 7 STEEL W/COATING A U B 100% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 1 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION ❑1 �0 �Lv�LAK ❑2 T ❑a CONM"1d°°"°°nnN' C:]4 BBCIWJMC U ❑5 w 71c PUP 99 o7H8R OElE4T0A iB51NG 1KNTOBNA LTAK 9E1ECfOR 9A11991Yn V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 RC-CONCMANUALIUATIN pRY 3 MO BORING ❑ 4 GAUGING AUTOMATIC TANK ❑5 MONITORING GROUND WATER ❑ e ANNUAL GTANK ❑ 7 MONITORING INTERSTITIAL ❑ 8 SIR 9 WEEKLY LY MANUAL ❑10 GING MONTHLY TANK ❑ 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-P E) 1.E TE DATE LAST USE ( AY/YR) 2 ESTIMATED OUA TY OF 3.WAS TANK FILLED WITH YES ❑ NO❑ SUBSTANCE RE INING GALLONS INERT MATERIAL? THIS FORM HAS BEEN C MPLETED UNDER PENALTY OF PEq3VRY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT TANK OWNER'S NAME DATE 'PRINK OnER NPE7 l J LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW7;1� 'T-b l / COm JURISDIC'nONI_L�JR FACIL—!�W TOANKR V `( STATE LD:# PERMIT NUMBER PERMIT APPROVED SYAMATE PERMIT EXPIRATION DATE THIS FORM MUST BE ACCOMPANIED BY A PERMIT AP' TION-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED, -M C MUST BE COMPLETED FOR INSTALLATIONS THIS FORM SHOULD BE ACCOMPANIED BY A PLO 1. FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING TGROUND STORAGE TANK REGULATIONS U;LATIONS FORM (6-95) • -4 11 .5 , ! v