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STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD d� . UNDERGROUND STORAGE TANK PERMIT APPLICATION -FORM B 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 DBA OR FACILITY NAME WHERE TANK IS INSTALLED: ! fi I. TANK DESCRIPTION COMPLETE ALL ITEMS— SPECIFY IF UNKNOWN A OWNERS TANK I.D.# O 1, B. MANUFACTURED BY: C. DATE INSTALLED(MO/OAYNEAR) D. TANK CAPACITY IN GALLONS: �O II.TANK CONTENTS IF A-1 15 MARKED,COMPLETE ITEM C. A, �1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C, to REGULAR UNLEADED ❑ 3 DIESEL ❑ 6 AVIATION GAS 2 PETROLEUM ❑ 80 EMPTY �1 PRODUCT t: PREMIUM UNLEADED ❑ 4 GASAHOL ❑ 7 METM85HANOL ❑ ❑ ❑ ❑ lc ��EUNLEADED O Jer FUEL OTHER(DESCR❑IBE IN REM D.BELOM 3 CHEMICAL PRODUCT 95 UNKNOWN 2 WASTE 2 LEAD99❑ D. IF(A1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A S.N: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.13,AND C.AND ALL THAT APPLIES IN BOX D AND A. TYPE OF 1 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 R. TANK 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 6 100% METHANOL COMPATIBLE W/FRP (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER C.INTERIOR ❑ 1 RUBBER LINED ❑ 2 ALKYD UNING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING LINING OR ❑ 5 GLASS LINING E!N 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 CORROSION PROTECTION E] 5 CATHODICPROTECTION ❑ 91 NONE E::]95 UNKNOWN 99 OTHER A E.SPILL AND OVERFILL,etc. SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) DROP TUBE YES_ NO STRIKERPLATE YES NO_ DISPENSER CONTAINMENT YES_ NO_ IV.PIPING INFORMATION CIRCLE A IFABOVEGROUNDOR U IF UNDERGROUND,BOTH IFAPPUCABLE A. SYSTEM TYPE A U 1 SUCTION AID PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION AD 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 a 100% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION AefL—,b5 UNKNOWN A U 99 OTHER D. LEAK DETECTION K1 IEC"A M.UNE Leal uiE TIGWrK% ❑3 CCNmMwG N ST ML ❑4 ELEC1110MC UNE ❑5 AUt=IIC NW ❑ yy OTRER OE1ECrOR TESTING Yg1TG31NG L&X 9ETECTpR SHUiGOYM V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK 2 MANUAL INVENTORY ❑LIATION 3 MONITORING ❑ 4 AUTOMA:GAUGING MONITOR]TANK ❑5 GROUND W TERN TESTING ❑ 7 CONTINUOUS MONTORNG INTERSTITIAL ❑ B SIR ❑ 9 WEETANKLY MANUAL ❑ 10 MONTHLY TANK ❑ 95 UNKNOWN 99 OTHER NG- VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) 1.ESTIMATED DATE LAST USED(MO/DAYNR) 2.ESTIMATED QUANTITY OF3.WAS TANK FILLED WITH YES EDNO❑ SUBSTANCE REMAINING GALLONS I INERT MATERIAL 7 THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT TANK OWNERS NAME DATE (PRINTED 6 SIGNATURE) LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY# TANK# STATE LD.# z O III PERMIT NUMBER I PERMIT APPROVED BYIDATE PERMIT EXPIRATION DATE AS L THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPUCI!'�N-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. FORB C MUST BE COMPLETED FOR INSTALLATIONS. THIS FORM SHOULD BE ACCOMPANIED BY A PLOT PL��LE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE 1;�I"z�9GROUNO STORAGE TANK REGULATIONS FORM B (6-95) ��