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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 O 5 CHANGE OF INFORMATION O 7 PERMANENTLY CLOSED ON ONE REM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE B TANK REMOVEDI-6 DBA OR FACILITY NAME WHERE TANK IS INSTALLED: I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A OWNER'S TANK I.D.R =a B. MANUFACTURED BY: !�`�•`"� C. DATE INSTALLED(MC/DAY/YEAR) (,x/YL.e/j� D. TANK CAPACITY IN GALLONSV�3�`''�Q�� II.TANK CONTENTS IF A-1 IS MARKED,COMPLETE ITEM C. A. 1 MOTOR VEHICLE FUEL O 4 OIL B. 7rEE----- 0. 1a REG"UNLEADED 3 DIESEL ❑ 6 AVIATION GAS �2 PETROLEUM ❑ 80 EMPTY �1 PRODUC1b PREMIUM UNLEADED 4 GABAHOL ❑ ] METHANOL 1c MIDGRADE UNLEADED O 5 JET FUEL ❑ 8 M85 3 CHEMICALPRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE 2 LEADED ❑ 99 OTHER(DESCRIBE IN ITEM D.BELOM IF(Al)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A S.x 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 O 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 ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE O 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 1 W% METHANOL COMPATIBLE W/FRP (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER C.INTERIOR ❑ I RUBBER LINED O 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC UNING LINING OR ❑ 5 GLASS LINING �6 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES— NO—)( D.EXTERIOR ❑ I POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC CORROSION x�LI.�- PROTECTION ❑ 5 CATHODIC PROTECTION `ate-'_S1 NONE El 95 UNKNOWN ❑ 99 OTHER E.SPILL AND OVERFILL,ah. 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 1 SUCTION A PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION U�/ 1 SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER �V C. MATERIAL AND 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 a 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 ❑ l I MB>JANJ ME IEAX T 2 ME IIEss ❑3 W$INrFAST 4 ELEc G ME 5 AMrCMATIC Pula DETECTESTING MDwmNTD LEAs OEIECT011 E:] SHUTDOWN E] 99 OTHER mA V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK 2 MANUAL RECONCILIATION O 3 VADOZE NG ❑ 4 GAUGINGC TANK O 5 �N TORINGTrR 6 ANNUNLGTANK 7 MONITORING INTERSTITIAL SIR 9`TAN GAUGINGAL ❑10 MESTNGY TANK ❑ 95 UNKNOWN 99 OTHER VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) T_/ 1.ESTIMATE ATE USED MOND 2.ESTIMATED QUANTITY OF 3.WASTFILLED WITH YES ❑ NOIyI SUBSTANCE REMAINING GALLONS IN MATERIAL? !""4 THIS F6RM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT TANK OWNER'S NAME DATE (PRINTED A SIGNATURE) LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW a3 a 3 COUNTY# JURISDICTION x FACILITY# TANK# VO STATE LDA Q - PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE 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 Pl RLE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE I-"nERGROUND STORAGE TANK REGULATIONS FORM B (6-95) ti, %w 'a - 9 8 OY�