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STATE OFCAUFORNIA ' *� r 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 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ON SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT 7� 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: !' I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN X OWNER'S TANK I.D.# B. MANUFACTURED `C+' J ._ C. DATE INSTALLED(MO/DAYNEAR) I D. TANK CAPACITY GALLONS: II.TANK CONTENTS IFA-1 IS MARKED,COMPLETE ITEM C A. ❑ I MOTOR VEHICLE FUEL 4 OIL B. C. LT 1a REGULAR UNLEADED DIESEL ❑ 6 AVIATION GAS ❑ 2 PETROLEUM ?�SO EMPTY ❑ 1 PRODUCT [7] 1D PREMIUM UNLEADED ❑ 4 GASAHOL ❑ 7 METHANOL 3 CHEMIC RODUCT 95 UNKNOWN 2 WASTE // E] is MIDGRADE UNLEADED E::] 5 JET FUEL ❑ B M85 ❑ ❑ ❑ 2 LEADED ❑ 99 OTHER(DESCRIB IN ffEM D.BELOY71 D. IF(Ai)IS NOT'MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S.#: ILL TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.B,AND C,AND ALL THAT APPLIES IN BOX D AND E i A. TYPE OF ❑ 1 DOUBLE WALL ❑ 3.SNGLE WALL WITH EXTERI914C NER ❑ 5 INTERNAL BLADOEM ^..(STEM,' ❑I 9S UNKNOWRJ SYSTEM ❑ 2 SINGLE WALL a ❑ 6 SINGLE WALL INA AULT ❑. 99j'_O`T'HER / J(S. B. TANK ❑ 1 BARE STEEL r.2 STAINLESS STE '�%11*��e C W/F RGLASS REINFORCED PLASnC MATERIAL ❑ 5 CONCRETE, 6 POLYVINYL CH RIDE ❑ 7 ALUMINUM �!_' METHAIIOL COMPATIBl.Ft9ARRP (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZE STEEL ❑ 95 UNKNOWN ED 99 OTHE C.INTERIOR ❑ I RUBBER LINED ❑ 2 ALKYD U G ❑ 3 EPDXY LINING ❑ 4 PHENOL( ,LINT LINING OR r-15 GLASS LINING F-18 UNUNE ❑ 95 UNKNOWN E] 99 OTHER �J COATING IS LINING MATERIAL COMPATIBLE WITH 100% ANOL7 YES_ NO_ / D.EXTERIOR ❑ 1 POLYETHYLENE.WRAP ❑ 2 COMING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC I j CORROSION - II PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE ❑ 95 UNKdIOWN ❑ 99 OTHER E.SPILL AND OVERFILL,aIC. SPILL O TAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) DROPCTUBE YES_ NO STRIKER PLATE YES_ NO DISPENSER CONTAINMENT YES Np E _ IV.PIPING INFORMATION - "CIRCLE A IFABO GROUNDOR U IF UNDERGROUND,BOTH IF APPLICABLE a. A. SYSTEM TYPE A U I SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION A U I SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNO \ 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 W/COATING A U a 100% METHf1W.j�COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED TEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION 1 MECXINIGL uW ❑2 UNE TIGIVKW —13 CO IXXIS INIERSnIUL ❑4 EISM0IIC UNE ❑5 AumOC PUW ❑ 99 oTH uETEmm 1ESIINa MoxnoRw6 LEb(DE1EcrDR ENum " V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK 2 MANUAL RECONCILIATION MONITORING ❑ 3 MONITORING ❑ 4 AUTOMATGAUGING IC TANK ❑5 GROUND MONITORINGTEfl 6 TESTING ❑ 7 MONITORINGCONTINUOUSINTERSTITIAL S SIR ❑ 9 WEEK LY MANUAL ❑10 M SNTHGY TANK ❑ 95 UNKNOWN ❑ 99 OTHER -TA VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) 1.ESTIMATED DATE LAST USED(MO/DAYNR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES ❑ NO F�� SUBSTANCE REMAINING GALLONS INERT MATERIAL? 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 (PRINTED 8 SIGNATURE) LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY# TANK STATE I.D.# [LEI I 41164T PERMIT NUMBER PERMIT APPROVED BYIDATE PERMIT EXPIRATION DATE J, 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 PLILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE',"--RGROUND STORAGE TANK REGULATIONS FORM B (6-95) voo