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STATE OFCAUFORNIA �`Os� STATE WATER RESOURCES CONTROL BOARD i"�®' =°4 UNDERGROUND STORAGE TANK PERMIT APPLICATION -FORM B COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT O 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ONSITE ONE REM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT /❑ 8 TEMPORARY TANK CLOSURE E] B TANK REMOVED 0 DBA OR FACILITY NAME WHERE TANK IS INSTALLED: So G✓�' D1C0 G I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A OWNER'S TANK I.D.# Z I B. MANUFACTURED BY: v-x C. DATE INSTALLED(MOIDAWYEAR) 119W D. TANK CAPACITY IN GALLONS: ac>. II,TANK CONTENTS IFA-1 IS MARKED.COMPLETE ITEM C. p. �' MOTOR VEHICLE FUEL ❑ 4 OIL B. C. 1A REGULAR UNLEADED ❑ 3 DIESEL [-] 6 AVIATIONGAS E:% PETROLEUM ❑ 80 EMPTY 1 PRODUCT PREMNM UNLEADED ❑ 4 GASAHOL ❑ 7 METHANOL ❑ tG MIDGRADE UNLEADED ❑ 5 JET FUEL ❑ 8 M85 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN 2 WASTE ❑ 2 LEADED ❑ 99 OTHER(DESCRIBE INTrEMD.BELO'M D. IF(A I)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S.#: Ill. 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 O 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 1T k BARE STEEL O 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD Wl FIBERGLASS REINFORCED PLASTIC MATERIAL U '.1-CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE WIFRP (PLImeryTank) ❑ 9 BRONZE O 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER C.INTERIOR ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY UNING ❑ 4 PHENOLIC LINING LINING OR ❑ 5 GLASS LININGIC�i 8 UNLINED F-195 UNKNOWN E:] 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES— NO— D.EXTERIOR Q 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC CORROSION PROTECTION S CATHODIC PROTECTION ❑ 91 NONE 94 UNKNOWN ❑ 99 OTHER E.SPILL AND OVERFILL,BTC. SPILL CONTAINMENT INSTALLED(YEAR) ERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) L, DROP TUBE YES NO_ STRIKER PLATE YES NO DISPENSER CONTAINMENT YES NO IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION SINGLE WALL A U 2 DOUBLE WALL 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 STEEL A U 3 POLYVINYL CHLORIDE(PVC)A U 4 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL W/COATING A U 8 IOD% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION 95 UNKNOWN A U 99 OTHER D. LEAK DETECTIONU 4 E 1 ME ML L#IE UAI( 2 UNE TIGXfN955 3 CGNRMgUS W SI LECn10MC NE MTC PIIMV ❑ DETECTOR ❑ 1E w NGMT(NIING ❑ LEAX 0EIECTOR ❑5 AIAM= ❑ 99 OTHER V.TANK LEAK DETECTION � ❑ 1 VISUAL CHECK 'ER 2 RECO CI A IONNUAL ORY [:] 3 VAMONIITORING E::] 4 GAUGING TANK ❑ 5 GROUND MONITORING TER 8 TESTINGTANK ❑ 7 CMOONTINOUROU INTERSTITIAL ❑ e SIR ❑ 9 WEEK GAUGING ❑10 MOTESTINGHLY TANK ❑ 95 UNKNOWN OTHER VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PUCE) 1.ESTIMATED DATE LAST USED MOND Y 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITN 9 SUBSTANCE REMAINING GALLONS INERT MATERIAL? YES ❑ C THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT TANK OWNER'S NAME DATE (PRINTEp A 51GNpTUREI LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY# TANK# STATE I.D.# m = I I I/ 11 1 zi `ViWA"_ PERMIT NUMBER PERMIT APPROVED BYIDATE PERMIT EXPIRATION DATE �6 THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLIC-_-N-FORMA,UNLESS A CURRENT FORMA HASBEENFILED. FOPII t�MUST BE COMPLETED FOR INSTA TIONS.THISFORM SHOULD BE ACCOMPANIED BY A PLOT P ILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE ?GROUND STORAGE TANK REGULATIONS FORM B (6.95) 1�