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.� STATE OF CALIFORNIA �"� STATE WATER RESOURCES CONTROL BOARD '? UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B �� =^ I 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 ❑ B TANK REMOVED O DBA OR FACILQY NAME WHERE TANK IS INSTALLED: ZO GlvF7� I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A OWNER'S TANK I.D.# (7 B. MANUFACTURED BY: C. DATE INSTALLED(MO/DAYNEAR) D. TANK CAPACITY IN GALLONS: �� &VZJ ) II.TANK CONTENTS IF A-1 IS MARKED,COMPLETE ITEM C. A1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C. to REGULAR UNLEADED 3 DIESEL ❑ 6 AVIATION GAS ❑ 2 PETROLEUM ❑ 80 EMPTY �, I PRODUCT ❑ tb PREMIUM UNLEADED 4 GASAHOL ❑ 7 METHANOL ❑ 8 MBS 3 CHEMICALPRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE O 2 MSD DE UNLEADED 99 OTHER(DESCRJET FUEL IBE N ITEM D.BELOW) D. IF(At)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A S.# III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A 3,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 ❑ 4 SINGLE WALL IN A VAULT ❑ 99 OTHER B. TANK I BARE STEEL O 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD Wt FIBERGLASS REINFORCED PLASTIC MATERIAL 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ B 10D% METHANOL COMPATIBLE W/FRP (Primmy Talk) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER C.INTERIOR ❑ 1 RUBBER UNED /ppO 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING LINING OR ❑ 5 GLASS UNING 6 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER COATING IS UNING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO_ D.EXTERIOR ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINF%RCBTIC CORROSION �yYY--�� Fa PROTECTION ❑ 5 CATHODIC PROTECTION O91 NONE ❑95 UNKNOWN �`I 99 OTHER E.SPILL AND OVERFILL,9(0. 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 ALV2 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION rV I SINGLE WALL A U 2 DOUBLE WALL A U 3 UNED 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 IDD% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION pLW95 UNKNOWN A U 99 OTHER D. LEAK DETECTION 1 MEC6 Mm Uri UE 2 USE nrHT9 ❑3 CMNUCUS NTEBS ❑4 ELECTRONIC UKQ s Aaarullc Purr ❑ 99 OTHER DET am TEsn90 MoHro m UAK oETECTaI A== V.TANK LEAK DETE ION ❑ 1 VISUAL CHECK MANUALRECONCIUATIONORY ❑ 3 MO ORING ❑ 4 GAUD NG AUTOMATIC TANK ❑ 5 MONITORING GROUND �R 6 TESTINGANNUALTANK ❑ 7 CONTINUOINTERSTITIAL O SIR ❑ 9 WE KL MANU ❑IO TESTINGY TANK El 95 UNKNOWN ❑99 OTHER MONITORINGVI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) 1.ESTIMATED DATE LAST USED(MO/DAY/YR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES ❑ NO❑ SUBSTANCE REMAINING GALLONS INERT MATERIAL 7 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 (PRIN 4SIGNATURE) LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY# TANK# STATE I.D:# m .9 yy% PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORMA HAS BEEN FILED. FORM C MUST BE COMPLETED FOR INSTALLATIONS.THIS FORM SHOULD BE ACCOMPANIED BY A PLOT P' FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THF 'IERGROUND STORAGE TANK REGULATIONS FORM B (6-95) `i '—w