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.� o ,« STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD ' UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B ��5 =^ t COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM, MARK ONLY ❑ i NEW PERMIT O 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: 57Z Gz4"ex I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A OWNER'S TANK I.D.Y d 1 B. MANUFACTURED BY: rN C. DATE INSTALLED(MO/DAYNEAR) D. TANK CAPACITY IN GALLONS: �d Yyp ILTANK CONTENTS IFA-11S MARKED,COMPLETE ITEM C. A. q?E�j MOTOR VEHICLE FUEL ❑ 4 OIL B. C. Rg 1a REGULAR UNLEADED ❑ 3 DIESEL ❑ 8 AVIATION GAS ❑ 2 PETROLEUM El 80 EMPTY 9k1 PRODUCT ❑ 10 PREMUM UNLEADED ❑ 4 GASAHOL ❑ ? METHANOL ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 1c MDGRADE UNLEADED ❑ 5 JET FUEL ❑ B M85 ❑ 2 LEADED ❑ 99 OTHER(DESCRIBE IN REM D.BELOYQ D. IF(At)IS NOT MARKED, ENTER NAME OF SUBSTAGE STORED C.A S.a 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 I DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 5 INTERNAL BLADDER SYSTEM ❑ 95 UNKNOWN SYSTEM 2 SINGLE WALL F-14 SINGLE WALL IN A VAULT ❑ 99 OTHER B. TANK 251 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP (PHDW T9RW ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER C.INTERIOR ❑ 1 RUBBER UNED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING LINING OR ❑ 5 GLASS LINING ® 6 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO— D.EXTERIOR ❑ 1 POLYETHYLENE WRAP O 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC CORROSION PROTECTION ❑ 5 CATHODIC PROTECTION El NONE 95 UNKNOWN E] 99 OTHER E SPILL AND OVERFILL,MC. 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 SUCTION A 2 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION 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 6 CONCRETE A U 7 STEE-1L W/COATING A U B 100% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION Ad295 UNKNOWN A U 99 OTHER D. LEAK DETECTION fll' ME ffw IME" ffyr2 UNE TK ITx 3 c NUM INIERSDML 4 B.EC11wMC UNE 5 AUTDMADC PUw OETELTIXI TESiN9 ❑ MJNTIXIN9 ❑ OF K 9ETECT011 ❑ SMIIOONNTI ❑ 99 OTHER V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK 2 RECOMANNAL CILIATION CILIATION INVENTORY ❑ 3 VADOZE MONITORING ❑ 4 GAUD MGIC TANK ❑5 GROUND WATER 6 ANNUATESTINGTANK ❑ 7 MONITORING INTERSTITIAL 8 SIR ❑ 9 EEKGAUG GAUGING MANUAL ❑10 MONTHLY TANK ❑ 95 UNKNOWN 99 OTHER VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) 1.ESTIMATED DATE LAST USED(MO/DAYNR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES O NO❑ SUBSTANCE REMAINING GALLONS I INERT MATERIAL? 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 (PRINTEDA9IGNATURE) LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION x FACILITY A TANK K STATE LDA m b G h PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE 3 -0x_ THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORMA,UNLESS A CURRENT FORMA HAS BEEN FILED. FORM C MUST BE COMPLETED FOR INSTALLATIONS. THIS FORM SHOULD BE ACCOMPANIED BY A PLOT F FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THI TERGROUND STORAGE TANK REGULATIONS FORM B (6-95) ��