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STATE OF CALIFORNIA +I STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B ;r 1 COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT a 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION O 7 PERMANENTLY CLOSED ON SITE ONE REM ❑ 2 INTERIM PERMIT O 4 AMENDED PERMIT 8 TEMPORARY TANK CLOSURE B TANK REMOVED .['1 DBA OR FACILITY NAME WHERE TANK IS INSTALLED: F V I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A OWNER'S TANK I.D.Y B. MANUFACTURED BY: C. DATE INSTALLED(MO/DAY/YEAR) D. TANK CAPACITY IN GALLONS: 3 O II.TANK CONTENTS IF A-1 IS MARKED,COMPLETE ITEM C. A. 1 MOTOR VEHICLE FUEL ED OIL B. C. ❑ 1a REGULAR UNLEADED ❑ 3 DIESEL ❑ 8 AVIATION GAS F-] 2 PETROLEUM ❑ BO EMPTY �1 PRODUCT ❑ It, PREMIUM UNLEADED ❑ 4 GASAHOL 7 METHANOL 1c MIDGRADE UNLEADED O 5 JET FUEL ❑ B M85 O 3 CHEMICAL PRODUCT 95 UNKNOWN 2 WASTE 2 LEADED O 99 OTHER(DESCRIBE IN ITEM D.BELOW) D. IF(p1)IS NOT MARKED. ENTER NAME OF SUBSTANCE STORED C.A.S.0: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A B AND C,AND ALL THAT APPLIES IN BOX D AND A. TYPE OF ❑ 1 DOUBLE WALL F--j 3 SINGLE WALL WITH EXTERIOR LINER ❑ 5 INTERNAL BLADDER SYSTEM ❑ 95 UNKNOWN SYSTEMI�2 SINGLE WALL F-14 SINGLE WALL IN A VAULT 99 OTHER B. TANK z 1 BARE STEEL O 2 STAINLESS STEEL F7 3 FIBERGLASS O 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL '❑ 5 CONCRETE ❑ 8 POLYVINYL CHLORIDE ❑ 7 ALUMINUM 8 100% METHANOL COMPATIBLE W/FRP (PNMMTank) ❑ 9 BRONZE O 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER C INTERIOR ❑ 1 RUBBER UNED O 2 ALKYD LINING 3 EPDXY LINING O 4 PHENOLIC LINING LINING OR ❑ 5 GLASS LINING Z2�l8 UNLINED 95 UNKNOWN 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 10D% METHANOL? YES_ NO D.EXTERIOR O 1 POLYETHYLENE WRAP O 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC CORROSION PROTECTION ❑ 5 CATHODIC PROTECTION 91 NONE 9S UNKNOWN Q 99 OTHER E.SPILL AND OVERFILL,BLC. 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 U 2 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION U 1 SINGLE WALL A U 2DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND1 BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A U 4 FIBERGLASS PIPE CORROSION A 5 ALUMINUM A U 8 CONCRETE A U 7 STEEL W/COATING A U 8 100% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION ❑i IEDN4MfAL LYIE 15AIL ❑2 UNE mxT M ❑3 w9lm WS NTDLS ❑4 M=KHc UK C:]5 mroMmc mw 99 OTHER DETECTOR TESTNO MONiOfffiIG LEAK 9ETELTCR $1111TODNN V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 RECONCILIATION NUAL INVENTORY 3 MONIITORING OZE ❑ 6 AUTOMATIC IC TANK 5 GROUND MONITORING ❑ 8 ANNUAL TESTING ❑ 7 MONITORING INTERSTITIAL 8 SIR ❑ 9 TANKKLY MANUAL ❑10 MONTHLY TANK 95 UNKNOWN ❑99 OTHER TING VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PUCE) 1.ESTIMATED DATE T USEL�1( O/D Y/YR) 2 ESTIMATED QUANTITY OF �" 3.WAS TANK FILLED WITH YES ❑ SUBSTANCE REMAINING e GALLONS INERT MATERIAL? THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT TANKERS NAME DATE (PRINTED651BNA TURET LOCAL AGENCY USE ONLY THE STATE LD.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY# NK 0 STATE 01 PERMIT NUMBER PERMIT APPROVED BYIDATE PERM 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 PLAN. FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS FOX i rt{695�7 9 1< S- j 2- Y 1/-4%6