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STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD sy ~o UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B ym' 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 , DBA OR FACILITY NAME WHERE TANK IS INSTALLED: qzv GGv I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A OWNER'S TANK I.D.9 Q B. MANUFACTURED BY: w C. DATE INSTALLED(MO'DAYNEAR) D. TANK CAPACITY IN GALLONS: QJ �a II.TANK CONTENTS IF A-1 IS MARKED,COMPLETE ITEM C. A. 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. ,,��// C. la REGULAR UMEADED 3 DIESEL ❑ 8 AVIAnONGAS 2 PETROLEUM ❑ 80 EMPTY �1 PRODUCT ❑ Z PREMIUM UNLEADED 4 GASAHOL ❑ 7 METHANOL ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN 2 WASTE E__1 is MIDGRADE UNLEADED E::] 5 JETFUEL ❑ B M85 ❑ 2 LEADED ❑ 99 OTHER(DESCRIBE IN ITEM D.BELom D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A S.N: 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 UNER ❑ 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 ❑ 4 STEEL CLAD W1 FIBERGLASS REINFORCED PLASTIC MATERIAL 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP (PHmaTy Tmk) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER 1 RUBBER LINED 3 EPDXY LINING 4 PHENOLIC LINING C.INTERIOR ❑ 2 ALKYD LINING ❑ ❑ LINING OR ❑ 5 GLASS LININGUNLINED ❑ 95 UNKNOWN ❑ 99 OTHER WIT COATING IS LINING MATERIAL COMPATIB H 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 UNKNOWN99 OTHER E SPILL AND OVERFILL,at. SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTIO QUIPMENT 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 SUCTION ACV PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION VV 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 B 100% METHANOL COMPATIBLE WIFRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION 5 UNKNOWN A U 99 OTHER D. LEAK DETECTION 1 rEawscu uxE IE4K 2 uxE TX4 KW 3 owls Ms IxrBennAL 4 nEc Ia UNE s AuroMAnc ww ❑ OLTECf011 TE$Tale M)NfgUM ❑ UMK DETECTOR ❑ SMoWnC 99 OTHER V.TANK LEAK DETabnON ❑ 1 VISUAL CHECK 2 MANUAL RECONCIIJATIONINVENTORY ❑ 3 VADOZE ING ❑ 4 AUTOGAUMATIC TANK ❑5 MONITORDWATER 6 ANNUNGTANK ❑ 7 MONITORING INTERSTITIAL g glq ❑ 9 TANEK GAUGING ❑10 MOTESTHLY TANK ❑ 95 UNKNOWN ❑99 OTHER NG VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) 1.ESTIMATED DATE LAST USED(MOIDAWYR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES ❑ NO ❑ SUBSTANCE REMAINING GALLONS INERT MATERIAL? THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT TANK OWNERS NAME DATE ("INTER 4 SIWIATURET LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY* JURISDICTION 0 FACILITY 6 TANK If STATE LD:# 4j PERMIT NUMBER PERMIT APPROVED BYIDATE 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- 'N. FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS FORM B (6-95)