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STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD +y ° 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 a ERMANENTLY CLOSED ON SITE ONE ITEM ❑ 2 INTERIM PERMIT El AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE 8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: �N. U I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN 7 V A OWNER'S TANK I.D.N B. MANUFACTURED BY: C. DATE INSTALLED(MO/DAY/YEAR) ' Z D. TANK CAPACITY IN GALLONS: / II.TANK CONTENTS IF A-1 IS MAR ED.COMPLETE ITEM C. 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C. 1a flEGUWi UNLEADED 3 DIESEL ❑ 6 AVIATIONGAS A' ❑ 10 PREMIUM UNLEADED ❑ 4 GASAHOL ❑ 7 METHANOL ❑ 2 PETROLEUM ❑ 80 EMPTY 1 PRODUCT ❑ 1C MIDGRADE UNLEADED ❑ 5 JET FUEL ❑ 8 M85 ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEAED O 99 OTHER(DESCRIBE IN REM D.BELOW) D. IF(Al)IS NOT MARKED. ENTER NAME OF SUBSTANCE STORED C.A S.N 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 ❑ 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR UNER E::] 5 INTERNAL BLADDER SYSTEM [:] 95 UNKNOWN SYSTEM L� ` 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 ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER C.INTERIOR ❑ 1 RUBBER UNED ❑ 2 O LINING F73 EPDXY LINING ❑ 4 PHENOLIC LINING LINING OR ❑ 5 GLASS LINING 6 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES— NO— D.EXTERIOR ❑ 1 POLYETHYLENE WRAP TING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC CORROSION PROTECTION ❑ 5 CATHODIC PROTECTION Zr 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER E.SPILL AND OVERFILL,etc. SPILL CONTAINMENT I LLED(YEAR) OVERFILL P NTION 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 U 2 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U W 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 E]1 MECHANICAL UNE LEAK LINE TIGHTNESS 3 COmINUWN INMRSTmAL 4 BECTRONIC UNE 5 AMTOWTIC PMR GE =R TESnaG ❑ MONITORING ❑ LEAK OETECMR ❑ mum" 99 OTHER S L V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 MANUALRECONCI INVENTORY ❑ 3 ATION MONITORING ❑ 4 AUTOMATGAUGING IC TANK ❑ 5 MONITORINGOUND TER ❑ 6 ANNUAL TESTINGTANK ❑ 7 MONITWOU INTERSTITIAL SIR ❑ 9 TAENK GA TESTING❑ 10 MONTHLY TANK ❑ 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PUCE) 1.ESTIMATED DATE LAST USED(MO/DAY/YR) 2.ESTIMATEDQUANTITY OF 3.WAS TANK FILLED WITH YES ❑ NO E]SUBSTANCE REMAINING GALLONS INERT MATERIAL? THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,A TO TH SAF MY KNOWLEDGE, IS TRUE AND CORRECT TANK OWNER'S NAME DAT (PRINT ED. ,.NA_ E)� �.�.r/ LOCAL AGENCY USE OLvNLY✓fTHE STATE II..D.NUMBER IS COMPOS OF TH U NUMBERS BELOW G V COUNTY N JURISDICTIN FACILITY N TANK a STATE I.DJ 17= PERMIT NUMBER PERMIT APPROVED BYIDATE PERMIT EXPIRATION DATE THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLI!'NTION-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 F FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THF 7ERGROUND STORAGE TANK REGULATIONS FORM B (6.95) 119100