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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 F-1 1 NEW PERMIT ❑ 3 RENEWAL PERMIT CR 1 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOS ONE REM F-] 2 INTERIM PERMIT F] d AMENDED PERMIT 6 TEMPORARY TANK CLOSURE ❑ B TANK REMOV DBA OR FACILITY NAME WHERE TANK IS INSTALLED: `� J ff4l tiu I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A OWNER'S TANK I.D.N B. MANUFACTURED BY' C. DATE INSTALLED(MOIDAYNEAR) D. TANK CAPACI N GA NS: II.TANK CONTENTS IF A-1 IS MARKED,COMPLETE ITEM C. A ��7 1 MOTOR VEHICLE FUEL ❑ d OIL B. C. 1a REGULAR UNLEADED ❑ 3 DIESEL ❑ 6 AVIATION GAS -ZI 2 PETROLEUM ❑ 80 EMPTY 1 PRODUCT ❑ 1c MIDGlb IMDEUM UUNLEADED NLEADED ❑ d JET FUEL ❑ 7 METHANOL -9}❑�'' ❑ ❑ 5 JET FUEL ❑ 8 M85 3 CHEMICALPRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED ❑ 99 OTHER(DESCRIBE IN REMD.BELOW) D. IF(Ai)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A S.#: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A,B,AND C. ALL THAT APPLIES IN BOX D AND A. TYPE OF ❑. 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH,6rrERuoA LINER ❑ 5 INTERNAL BLADDER SYSTEM ❑ 95 UNKNOWN SYSTEM ❑ 2 SINGLE WALL ❑ 4 SINGLE WALL IN�VAULT ❑ 99 OTHER B. TANK ❑ 1 BARE STEEL ❑ 2 STAINLESS STEIN. ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL oLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANI$D STEEL ❑ 95 UNKNOWN ❑ 99 OTHER C.INTERIOR ❑ I RUBBER UNED ❑ 2 ALKYDAINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING LINING OR ❑ 5 GLASS LINING ❑ 6 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WTH 1012�6 METHANOL? YES_ NO— D.EXTERIOR ❑ 1 POLYETHYLENE WRAP ❑ W COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC CORROSIONg1 NONE ❑95 UNKNOWN ❑ 99 OTHER PROTEC11ON ❑ 5 CATHODIC PROTECTION SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) E.SPILL AND OVERFILL,BTC. 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 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 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 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 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. M:CHNNGIL UNE UBW 2 INE TNXfM1EE3 3 C 111 i WTEFSrInk 1 FLECiRONIC UNE 5 AUrDIMTK PNP 99 OTHER D. LEAK DETECTION ❑ Ocg ❑ wnw ❑ KOMrmieO ❑ IbN(oElEcroR ❑ 9utoowN ❑ V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 MANUAL ECONCILIAT ONORY ❑ 3 MO�NOITORING ❑ d GAUL NG AUTOMATIC TANK ❑5 MONITORINOUND G ❑ 6 TESTINGANNUAL ❑ 7 MONITOR MONTHL UG INTERSTITIAL ❑ 8 SIR ❑ 9 TANK GAUGINGAL ❑70 TES NGY TANK ❑ 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PUCE) 1.ESTIMATED DATE LAST USED(MO/DAYNP) 2.ESTIMATED QUANTITY 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 DATE (PRIMED 6 SIGNATUREI LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION N FACILITY# TANK# STATE I.D:# m = FTT= 3 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 PL"' R!LE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS FORM B (6-95) 411110 q-lu—