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STATE OFCALIFORNIA V STATE WATER RESOURCES CONTROL BOARD a 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 T K REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: Z 7 �s I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A. OWNER'S TANK I.D.M B. MANUFACTURED BY: v �" C. DATE INSTALLED(MOIDAYNEAR) 'L D. TANK CAPACITY IN GALLONS: oa a II.TANK CONTENTS IFA-1 IS MARKED,COMPLETE ITEM C. A / MOTOR VEHICLE FUEL ❑ d OIL B. C to REGULAR UNLEADED 3 DIESEL AVIATION GAS 2 PETROLEUM ❑ BO EMPTY � PROWCT ❑ tE PREMIUM UNLEADED 4 GASAHOL METHANOL ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN 2 WASTE ❑ Ic MIDGRADE UNLEADED 5 JET FUEL 8 M85 ❑ 2 LEADED 89 OTHER(DESCRIBE N ITEM D.BELOM D. IF(0.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S.I: 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 ❑ 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 ❑ 8 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP (PDmmy TmIQ 0 9 BRONZE ❑ 10 GALVANIZED STEEL 5 UNKNOWN ❑ 99 OTHER C.INTERIOR ❑ I RUBBER UNED ❑ 2 ALKYD LINING n 3 EPDXY UNING ❑ 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 ❑ 2 COATING3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC CORROSION PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONEUNKNOWN 99 OTHER E.SPILL AND OVERFILL,BSC. 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 I SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLEPIPING A U 99 OTHER B. CONSTRUCTION A U I SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH Afi�IP UNKNOWN A U 99 OTHER C. MATERIAL AND A U 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 6 CONCRETEA U 7 STEEL /COATING A U 8 100% METHANOL COMPATIBLE WffRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION U NKNOWN A U 99 OTHER D. LEAK DETECTION 1 N CNNacu UNE LEAIc 2 UNE 1MKIrass 3 CCN9WCw INIli 11UL 4 EIBCmONC UN: 5 AUTCW,nC PVIa ❑ OEiE4TOP ❑ IESTPq ❑ M TORM3 IFAAf RT'eCtOP 91UiWVM ❑ 99 OTHER V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 MANUAL ONCILIATIONORY ❑ 3 MON ORING ❑ 4 GAUGING MONITORING TANK ❑5 MONITORINGUND TER ❑ 6 ANNUALTESTING ❑ 7 CONTINU U INTERSTITIAL ❑ 8 SIR ❑ 9 WE K LYA MAIrINUAL E]10 MONTHLY TANK 95 UNKNOWN ❑ 99 OTHER MNITOTFqTING VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) 1.ESTIMATED DATE LAST USED(MOIDAYNR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES ❑ NO❑ SUBSTANCE REMAINING GALLONS INERTMATERIAL7 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 (PRINTIM8 81GNAT.IRE) LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY N JURISDICTION 9 FACILITY 9 STATE I.DJ m = I 10 C6 �2 PERMIT NUMBER PERMIT APPROVED BYADATE PERMI THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORM A,UNLESS A CURRENT FORMA HAS BEEN FILED. FORM C MUST BE COMPLETED FOR INSTALLATIONS.THIS FORM SHOULD BE ACCOMPANIED BY A PLOT PLAN. RLE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS FORM B (6-95)