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• ~� STATE OF CALIFORNIA *MAO, STATE WATER RESOURCES CONTROL BOARD p mom, e 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 REM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE B TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: I. TANK DESCRIPTION COMPLETE ALL ITEMS— SPECIFY IF UNKNOWN A. OWNERS TANK I.D.# B. MANUFACTURED BY: C. DATE INSTALLED(MOIDAYNEAR) D. TANK CAPACITY IN GALLONS: II.TA11NNKKK CONTENTS IFA-11S MARKED,COMPLETE ITEM C. p ISI 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C. 1e REGUL4R UNLEAOm O 3 DIESEL ❑ 6 AVIATIONGAS /❑ 2 PETROLEUM ❑ 80 EMPTY ❑ i PRODUCT 1b PPEMMM UNLEMm ❑ 4 GASAHOL ❑ 7 METHANOL 8 MBS ❑ 3 CHEMICAL PRODUCT ❑ BS UNKNOWN ❑ 2 WASTE O 2 DEDE UNLEADED 0 99J0 ERET EDESCOW ITEM D.BELOW) D. IF(pi)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S.# 111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A B,AND C.AND ALL THAT APPLIES IN BOX D AND E A. TYPE OF F7 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 5 INTERNAL BLADDER SYSTEM ❑ 95 UNKNOWN SYSTEM PL 2 SINGLE WALL ❑ 4 SINGLE WALL IN A VAULT ❑ 99 OTHER B. TANK 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL S CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP (PrlmeryTwk) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER C.INTERIOR ❑ 1 RUBBER UNED 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOUC LINING LINING OR ❑ 5 GLASS LINING 6 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER COATING IS UNING MATERIAL COMPATIBLE WITH 10016 METHANOL? YES_ NOyV, D.EXTERIOR ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC CORROSION PROTECTION ❑ 5 CATHODIC PROTECTION 91 NONE ❑95 UNKNOWN ❑ 99 OTHER E SPILL AND OVERFILL,ate. SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) DROP TUBE VES NO S IKER PLATE YES NO DISPENSER CONTAINMENT YES_ NOt�_41 IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND,BOTH IFAPPUCABLE A. SYSTEM TYPE A U I SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLEPIPING A U 99 OTHER B. CONSTRUCTION <U)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 1 BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A U 4 FIBERGLASS PIPE CORROSION A 5 ALUMINUM A U 6 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 ' 3r< MOR LIKE LEAK 2 uxE nGxrraEss 3..NTE9snmt ELEcmoMJTMVC PULP 99 OTHER ❑ OETE4TOR ❑ TE&TP1G ❑ NONTOrUiO ❑4 C U.LEAK DETECTOR ❑5 AI94ROmW V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 MANUAL ONCILI VENTTION RY ❑ 3 MO ORING ❑ 4 GAUGING C TANK ❑5 GROUND WATER 6 ANNUALTANK ❑ TESTING 7 MONITORINGINTERSTITIAL ❑ 8 SIR 9 WEEKLY MGAUANUAL ❑10 MONTHLY TANK ❑ 95 UNKNOWN OTHER TING VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) �J 1.EST TED LAST D(MOIDAYNR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES ❑ NO 17(L SUBSTANCE REMAINING GALLONS INERT MATERIAL 7�`r 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 (PRINTED&SIGNATURE) '\ /�/ ry LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW 6 oZ 3 (I D& b COUNTY# JURISDICTION# FACILITY# TANK# STATE 101 PERMIT NUMBER PERMIT APPROVED BYIDATE PERMIT EXPIRATION DATE Q / THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORMA,UNLESS A CURRENT FORM A HAS BEEN FILED. FORM C MUST BE COMPLETED F MSTALLAONS.THIS(FORM SHOULD BE ACCOMPANIED BY A PLOT PU ILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE V'- -9GROUND STORAGE TANK REGULATIONS FORM (6-95) ,_ .�� FOR0034BRW