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>.o/ STATE OFCAUFORNIA *ftft/ �1 STATE WATER RESOURCES CONTROL BOARD + UNDERGROUND STORAGE TANK PERMIT APPLICATION-FORM B '"�'I =g COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. 1 MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ON SITE ONE REM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT6 TEMPORARY TANK CLOSURE ❑ ❑ 8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: 3 13 I. TANK DESCRIPTION COMPLETE ALL ITEMS— SPECIFY IF UNKNOWN A OWNER'S TANK I.D.t B. MANUFACTURED B C. DATE INSTALLED(MOIDAYNEAR) D. TANK CAPACI IN GALLONS: II.TANK CONTENTS IFA-1 IS MARKED,COMPLETE ITEM C. A ❑ 1 MOTOR VEHICLE FUEL 4 OIL S. C 1a REGULAR UNLEADEDO 3 DIESEL ❑ e AVIATION GAS ❑ 2 PETROLEUM 80 EMPTY ❑ 1 PRODUCT ❑ lb PREMIUM UNLEADED ❑ 4 GASNROL ❑ 7 METHANOL ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN 2 WASTE ❑ Ic MIDGRADE UN-FADED ❑ 5 JETFUEL ❑ 8 M85 ❑ 2 LEADED ❑ 99 OTHER(DESCRIBE M REM D.BFLONT D. IF(A1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A S.0: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A,B.AND C,4ALL THAT APPLIES IN BOX D AND E A. TYPE OF ❑ I DOUBLE WALL ❑ 3 SINGLE WALL WITH ]OR LINER ❑ 5 INTERNAL BLADDER SYSTEM O 95 UNKNOWN SYSTEM ❑ 2 SINGLE WALL ❑ 4 SINGLE WALL IN VAULT F1 99 OTHER S. TANK ❑ I BARE STEEL O 2 STAINLESS STE ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL IDE ❑ 7ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP (PHmary Tank) 8 BRONZE ❑ 10 GALVANIEL ❑ 95 UNKNOWN ❑ 99 OTHER C.INTERIOR ❑ I RUBBER LINED ❑ 2 ALKYDL ING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC UNING LINING OR F—] 5 GLASS LINING ❑ a UN IN ❑ 95 UNKNOWN ❑ 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 100% ETHANOL? YES_ NO— D.EXTERIOR ❑ I POLYETHYLENE WRAP 2 C ATNG ❑ 3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC CORROSION PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 ONE ❑95 UNKNOWN ❑ 99 OTHER E.SPILL AND OVERFILL,BTC. SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) DROP TUBE YES_ N STRIKER PLATE YES_ NO_ DISPENSER CONTAINMENT YES_ NO W.PIPING INFORMATION CIRCLE A IF AB EGROUND 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 WALL A U 2DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND A U 1 BARE STEELA 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 8 100% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED/EEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION 1 NEG4NAm UNE O 2 LNE 11GHTN ❑3 GON ..INIERSRML ❑4 FLECIROMC UNE051 IRCNATIC Ruw ❑ 99 OTHER GETECfOR TE514I# MONTOPWO LFN(OEfECTOR SXU190KN V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK 2 RECONCILIATIONNUAL INVENTORY ❑ 3 MAODNOZE ITORING ❑ 4 GAUG NG AUTOMATIC TANK ❑ 5 MON MONITOOUND RING ❑ 6 ANNUALTESTING ❑ 7 CONTIINMONTOR NG INTERSTITIAL B SIR ❑ 9 TMIEK GAUGANGAL 10 TESNTINGY TANK ❑ 95 UNKNOWN ❑99 OTHER VI.TANK CLOSURE INFOR ATION(PERMANENT CLOSURE IN-PUCE) 1.ESTIMATED DATE LAST USED(MOIDAY/YR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES ❑ NO❑ SUBSTANCE REMAINING GALLONS I 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 a SIGNATURE) LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY# TANK# STATE I.Dl 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 INST LLA ONS�THIS FFM SHOULD BE ACCOMPANIED BY A PLOT PLAN. FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS FORM B (6-95) (0-/ l I uq I&AZIL, y