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STATE OF CALIFORNIA lq / � ., STATE WATER RESOURCES CONTROL PPL(BOARDmom, ' R UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B �;p ,� e� 1 COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION7 PERMANENTLY CLOSED N SITE ONE REM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE B TANK REMOVED In DBA OR FACILITY NAME WHERE TANK IS INSTALLED: & 51- V I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A OWNER'S TANK I.D.# 8. MANUFACTURED BY: C. DATE INSTALLED(MOIDAYJYEAR) D. TANK CAPACITY IN GALLONS: II.TANK CONTENTS IF A-1 IS MARKED,COMPLETE ITEM C. '-19A, 1 MOTOR VENICE FUEL a 4 OIL C. 'Ej1e REGULAR UNLEADED O 3 DIESEL ❑ 6 AVIATIONGAS 2 PETROLEUM ❑ 80 EMPTY I PRODUCT ❑ 1b PREMIUM UNLEADED ❑ 4 GASAHOL ❑ 7 METHANOL ❑ lc MOGRADE UNLEADED ❑ 5 JET FUEL ❑ 8 M85 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE 2 LEADED ❑ 99 OTHER(DESCRIBE IN ITEM D.BELONG D. IF(AI)IS NOT MARKED. ENTER NAME OF SUBSTAGE STORED C.A S.#: IIL TANK CONNSST-RUCT10N MARK ONE ITEM ONLY IN BOXES A B,AND C,AND ALL THAT APPLIES IN BOX D AND E A TYPE OF I SYSTEM Iv 2 DOUBLE WALL ❑ 4 SINGE WALL W A VTH EXTERIOR LINER O 599INTER AL BLADDER SYSTEM ❑ 95 UNKNOWN OTHER B. TANK ❑ I BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD N FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE O 6 POLYVINYL CHLORID7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE WIFRP (PNmYy TM1k) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL 95 UNKNOWN 99 OTHER C.INTERIOR ❑ I RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY UNING 4 PHENOLIC LINING LINING OR ❑ 5 GLASS LINING ❑ 6 UNLINED t� 95 UNKNOWN ❑ 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 10D% METHANOL? ��\ IY��—ESIII— NO— D.EXTERIOR ❑ 1 POLYETHYLENE WRAP E] ❑ 4 FIBERGLASS REINFORCED PLASTIC CORROSION PROTECTION ❑ 5 CATHODIC PROTECTION El 91 NONE 95 UNKNOWN O 99 OTHER SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) E SPILL AND OVERFILL,BIC. 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 APPUCABLE 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 A U 1 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 i 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 N COATING A U B 100% METHANOL COMPATIBLENFRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER 1 1ECNNa.LL LME LEAN U 4 TMK W C UG INTFJ151RLLL BECBIIX4C NE 5 AUIq =RAP D. LEAK DETECTION ❑ DETECTOR ❑2 UK TESRMI ❑3 MOMTgIMO ❑ LEM DETECTOR 9MDOvm ❑ 99 OTHER V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 RMECOU CIUATIONOflY ❑ 3 MAONNIITORING ZE ❑ 4 GAUGWG AUTOMATIC: TANK ❑5 GROUND WATER ❑ 6 ANNUALTESTING ❑ 7 MONITORING INTERSTITIAL O 8 SIR ❑ 9 WEEKLYA MANGA ❑ 10 MOTESNTHLY TANK ❑ 95 UNKNOWN ❑ 99 OTHER ING VI,TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PUCE) 1.ESTIMATED DATE USED(MO/DAWYR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES ❑ NO ❑ -Z O! C� jt� SUBSTANCE REMAINING GALLONS INERT MATERIAL 7 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 (PRIMED d SIGNATURE( LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY M JURISDICTION# FACILITY# TANK M STATE I.D.# O rL3JVM PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE 5 THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLP'ATION-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 r FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING TH' TRGROUND STORAGE TANK REGULATIONS FORM B (6-95)