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... �.. STATE OF CALIFORNL4 ^`� .` t' STATE WATER RESOURCES CONTROL BOARD o 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 ONSITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT 8 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A OWNERS TANK 1.D.f MUFACTURED BY C. DATE INSTALLED(MO/DAWYEAR) D. TANK CAPACI N GALLONS: II.TANK CONTENTS IF A-1 IS MARKED.COMPLETE ITEM C. A ❑ 1 MOTOR VEHICLE FUEL 4 OIL aC. 19 REGULAR UNLEADED 3 DIESEL ❑ 8 AVIATIONGAS 2 PETROLEUM ❑ 80 EMPTY 174 1 PRODUCT ib PREMIUM UNLEADED 4 GASAHOL ❑ 7 METHANOL 1C MIDGRADE UNLEADED ❑ 5 JET FUEL ❑ 8 M85 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED ❑ 99 OTHER(DESCRIBE IN ITEM D.SELLA D. IF(A1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A S.f III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A B.AND C. ALL THAT APPLIES IN BOX D AND E A. TYPE OF DOUBLE WALL ❑ 3 SINGLE WALL WITH IOR LINER ❑ 5 INTERN&BLADDER SYSTEM ❑ 95 UNKNOWN SYSTEM ❑ 2 SINGLE WALL ❑ 4 SINGLE WALL IN VAULT ❑ 99 OTHER s B. TANK ❑ 1 BARE STEEL ❑ 2 STAINLESS SL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD WI FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 8 POLYVINYL LORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP (PIIINIy Tak) ED BRONZE ❑ 10 GALVANI STEEL ❑ 95 UNKNOWN ❑ 99 OTHER C.INTERIOR ❑ I RUBBER LINED ❑ 2 A NINE ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING LINING OR ❑ 5 GLASS LINING ❑ 8 UN ED ❑ 95 UNKNOWN ❑ 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 1 METHANOL? YES— NO— D.EXTERIOR ❑ 1 POLYETHYLENE WRAP ❑ COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC CORROSION PROTECTION ❑ 5 CATHODIC PROTECTION 91 NONE ❑95 UNKNOWN ❑ 99 OTHER E.SPILL AND OVERFILL,BTO. SPILL CONTAINMENT IN ALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) DROP TUBE YES z NO_ STRIKER PLATE YES_ NO_ DISPENSER CONTAINMENT YES_ NO_ IV.PIPING INFORMATION CIRCLE IF ABOVE GROUND OR U IF UNDERGROUND,BOTH IF APPLICABLE 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 ALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND A U 1 SAFeIEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A U 4 FIBERGLASS PIPE CORROSION A U 5 M A U 8 CONCRETE A U 7 STEELW/COATING A U 8 100% METHANOL COMPATIBLE W/FRP PROTECTION A U 9LVANIZED STEEL A U 10 CATHODIC PROTECTION A U 25 UNKNOWN A U 99 OTHER D. LEAK DETECTION xFR 2 INE TDI11NE38 s carruucus NTBmm/L ❑4 WUNT COR TE!ITNG ❑s AuroM4nc PULP OTHER V.TANK LEAK DETEC ON ❑ 1 VISUAL CHEC ❑ 2 MANUALRECONC NORY ❑ 3 MOMOTORING ❑ 4 GAUGING TANK ❑5 GROUNDWATER ❑S ANNUALTESTINTANK ❑ 7 NOU)U INTERSTITIAL ❑ 8 SIR ❑ 9 WEEKLTANK Y MANUAL _]10 M SHINGLY TANK ❑ 95 UNKNOWN ❑W OTHER VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) 1.ESTIMATED DATE LAST USED(MO/DAY/YR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES ❑ NO❑ 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 6 SIGNATURE) LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY f JURISDICTION M r---��FACILITY f TANK f EPERMITNUMBET ATE I.Dl 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 INSTACLATIOkS.DRS FOR111 SHOULD BE ACCOMPANIED BY A PLOT PLAN. FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS '9 1 y REGULATIONS ,L 1, 'f . FORME (6-95) (N�Y"� SAA-'