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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 ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSE TE ONE REM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE l2j�B TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A OWNER'S TANK I.D.f S. MANUFACTURED BY: C. DATE INSTALLED(MO/)AWYEAR) 4�F/,57 I D. TANK CAPACITY IN GALLONS: ^ Z Q o II.TANK CONTENTS IF A-1 IS MARKED.COMPLETE Am C. A ❑ 1 MOTOR VEHICLE FUEL O 4 OIL B. C. to REGULAR UNLEADED 3 DIESEL ❑ 6 AVIATIONGAS PETROLEUM ❑ BO EMPTY 2ri PRODUCT 1b PREMRRA UNLEADED 4 GASAHOL ❑ 7 METHANOL .142 iG MIDGRADE UNLEADED 5 JET FUEL ❑ 8 M85 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE 2 LEADED 40 P9 OTHER(DESCRIBEIN TWD.BELOW) D. IF(AI)IS NOT MARKED. ENTER NAME OF SUBSTANCE STORED , jf L C.A.S.f: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A B.AND C.AND AULYFIAT APPLIES IN BOX D AND E A. TYPE OF ❑ 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 5 INTERNAL BLADDER SYSTEM ❑ 95 UNKNOWN SYSTEM Zr SINGLE WALL ❑ 4 SINGLE WALL IN A VAULT ❑ 99 OTHER ICJ 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 ❑ B IM% METHANOL COMPATIBLE WIFRP (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN a 99 OTHER C.INTERIOR ❑ I RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING Ej 4 PHENOLIC LINING LINING OR ❑ 5 GLASS LINING ❑ 6 UNLINED l2'95 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 PROTECTION ❑ 5 CATHODIC PROTECTION 91 NONE ❑95 UNKNOWN ❑ 99 OTHER E SPILL AND OVERFILL,liC. SPILL CONTAINMENT INSTALLED(YE4 OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) DROP TUBE YES_ NO STRIKER PLATE YES_ No DISPENSER CONTAINMENT VES_ NO IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND.BOTH IF APPLICABLE A. SYSTEM TYPE A 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION A cQ 1 SINGLE WALL A U 2 DOUBLE WALL A U 3 UNED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND 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 1:1I MECIVMUL .14 IEAA ❑2 UNC i NEW r-13 CM1MpIR INTERSTR4l ❑A EEECTRGLAC UAE ❑5 AVla m EVA, gg OTHER pETE=11 TESTING MgiIGAING DAA 9ETEcn3R 9MODAN V.TANK LEAK DETECTION ❑ I VISUAL CHECK ❑ 2 MANUAL RECONCILIATIONORY ❑ 3 MONITORING El GAUGING AUTOMATIC TANK ❑5 GROUND MONITORINGTER ❑ TANK 6 TESTING ❑ 7 MONITORING CONTINUOUSINTERSTITIAL ❑ 8 SIR ❑ 9 TANKGA MANUAL ❑10 MONTHLY TANK U 1"5 UNKNOWN ❑ 99 OTHER TING VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) 1.ESTIMATED DAT LAST USE (MC/DAYNR) 2.ESTIMATED OUANTITY OF� 3.WAS TANK FILLED WITH YES NO❑ 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 v DATE (PRINTED LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBER BELOW COUNTY a JURISDICTION a FACT r ! TANK f STATE I.D.# m 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 PLAN E THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UP' -GROUND STORAGE TANK REGULATIONS p( FORM 9 16.85) L� y ' Tom. j4Q