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STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B , l COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ON SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED O DBA OR FACILITY NAME WHERE TANK IS INSTALLED: I. TANK DESCRIPTION COMPLETE ALL ITEMS— SPECIFY IF UNKNOWN A OWNER'S TANK I.D.# O B. MANUFACTURED BY: v C. DATE INSTALLED(MWAYIYEAR) D. TANK CAPACITY IN GALLONS: II.TANK CONTENTS IF AA IS MARKED,COMPLETE ITEM C. ,L ❑ 1 MOTOR VEHICLE FUEL 4 OIL B. C. ❑ to REGULAfl UNLEADED ❑ 3 DIESEL ❑ 6 AVIATION GAS ❑ E:l 4 GASAHOL 7 METHANOL 2 PETROLEUM O EMPTY ❑ 1 PRODUCT ❑ 1D PREMIUM UNLEADED ❑ ❑ le MIDGRADE UNLEADED 5 JETFUEL ❑ B M85 ❑ 3 CHEMICALPRODUCT ❑ 95 UNKNOWN 2 WASTE ❑ 2 LEADED 99 OTHER(DESCRIBE IN ITEM D.BELOW) D. IF(A1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED �� L G/� 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 OF1 DOUBLE WALL F-13 SINGLE WALL WITH EXTERIOR LINER ❑ 5 INTERNAL BLADDER SYSTEM E::] 95 UNKNOWN SYSTEM E2 SINGLE WALL ❑ 4 SINGLE WALL IN A VAULT ❑ 99 OTHER B. TANK 'Eq—L BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE O 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ a 100% METHANOL COMPATIBLE W/FRP (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER C.INTERIOR ❑ 1 RUBBER LINED 2ALKYD LINING F—] 3 EPDXY LINING 4 PHENOLIC LINING LINING OR ❑ 5 GLASS LINING 96 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO— D.EXTERIOR ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC CORROSION PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE 95 UNKNOWN ❑ 99 OTHER E SPILL AND OVERFILL,6L0. 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 OR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCRON A U 2 PRESSURE 45>3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION ACV 1 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 8 CONCRETE A U 7 S��.F1]W�/COATING A U 8 100% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION AILL�+ UNKNOWN A U 99 OTHER D. LEAK DETECTION 1 #ECWIR MIE IEA1c 2 uxE 1XwrxEu 3 ca6nMlo96 NrEnsIrrx 4 ELECT% UNE 5 AuroMAnc RKP ❑ EEiEtTOR ❑ IESRKKI ❑ MOM mala ❑ [FAN OEIECfOR ❑ 3NNI90WN ❑ 99 OTHER V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 RECONCILIATION CILIATIONNUAL ORY ❑ 3 VAOZEMONIITORING ❑ 4 AUTOMATGAUGNGIC TANK ❑5 MOONTORING WATERROUND ❑ 6 TESTING TANK ESTIING ❑ 7 CONTINUMONITORU INTERSTITIAL ❑ 8 SIR ❑ 9 WE K LY MANUAL ❑10 MG TESTMINGY TANK ❑ 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) 1.ESTIMATED DATE LAST U D( AYlY ) 2. SUBSTANCE REMAININGESTITED QUANTITY GALLONS 3 WASNERT MATERIAL?K FILLED YES ❑ NO❑ �� 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 (PRINTED 881G 1`.IREI LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY# TANK# p Ei— STATE I.D.# 3 / /8A'3,177 PERMIT NUMBER P RMIT APPROVED BWDATE PERM IT EXPIRATION DATE II i 6 FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. FORM r MUST BE COMPLETED FOR INSTALLATIONS.THIS FORM SHOULD BE ACCOMPANIED BY A PLOT PLAN, 'THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UN! 90UND STORAGE TANK REGULATIONS 'M a (6.95) !/