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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. ❑ ❑ 7 PERMANENTLY CLOSED ON MARK ONLY ❑ 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION / ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN S. MANUFACTURED BY: A. OWNERS TANK I.D.• D D. TANK CAPACITY IN GALLONS: C. DATE INSTALLED(MO/DAY/YEAR) IL TANK CONTENTS IF A-1 IS MARKED,COMPLETE ITEM C. 8 AVIATION GAS 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C, 1#REGULAR UNLEADED ❑ 3 DIESEL ❑ A /r-l"REMIUM UNLEADED ❑ 4 GASAHOL ❑ 7 METHANOL '2 PETROLEUM ❑ BO EMPTY i 1 PRODUCT ❑ 1t MIDGRADE UNLEADED O 5 JETFUEL ❑ 8 M85 ❑ 3 CHEMICALPRODUCT ❑ 95 UNKNOWN - ❑`2 WASTE ❑ 2 LEADED ❑ 99 OTHER(DESCRIBE M REM D.BELOM D. IF(A.1)IS NOT MARKED. ENTER NAME OF SUBSTANCE STORED C.A.S.#: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A B,AND C.AND ALL THAT APPLIES IN BOX D AND E A. TYPE OF F-1I DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR UNER ❑ 5 INTERNAL BLADDER SYSTEM ❑ 95 UNKNOWN SYSTEM ❑ 2 SINGLE WALL F-14 SINGLE WALL IN A VAULT ❑ 9B OTTER ❑ 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B. TANK F-1 MATERIAL ❑ 5 CONCRETE 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM E:] 8 100% METHANOL COMPATIBLE WIFRP (Primary Turk) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER F-11 RUBBER LINED F-12 ALKYD LINING F73 EPDXY LINING ❑ 4 PHENOLIC LINING C.INTERIOR LINING OR ❑ 5 GLASS LINING ❑ 8 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO— D.EXTERIOR ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC CORROSION 91 NONE ❑95 UNKNOWN ❑ 99 OTHER PROTECTION ❑ 5 CATHODIC PROTECTION ❑ SPILL CONTAINMENT I TALLED(YEAR) OVERFl LP EVENTION EQUIPMENT INSTALLED(YEAR) E SPILL AND OVERFILL,BSC. DROP TUBE YES NO_ S IKER PLATE YES NO_ DISPENSER CONTAINMENT ES— NO IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION A-402 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION A U I SINGLE WALL 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND A U I BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) 4 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEELW/COATING A U B 100% METHANOL COMPATIBLENFRP PROTECTION A U GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION I MEGNNAGL UNE LAK ❑2 WE MIMIESS ❑3 CgmM1W5 IWEMS ❑/EILCiRfmIC UNE O 5 Atff M C PUMP O 99 OTHER oElEcroR TEsm+o ImmTmm3 UAK NETECMA Sxt r l V.TANK LEAK DETECTION ❑ i VISUAL CHECK ❑ 2 REECCOU CILIATIONAL ORV ❑ 3 MONIITORING VAOZE ❑ 4 GAUGINAUTOMATG TANK ❑ 5 MONITORINGROUND G F-1e TE�NLGTANK 7 CONTINUOUS MONITORINGINTERSTITIAL ❑ 8 SIR ❑ 9 WE4EK LYA MANUAL ❑10 ME NTHLY TANK ❑ 95 UNKNOWN 89 OTHER STING I.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) VIA 1.ESTIMATED DATE LAST USED(MODAWYR) 2.ESTIMATED OUANTITY OF 3.WAS TANK RLLED WITH YES C SUBSTANCE REMAINING GALLONS INERTMATERIAL? [:] ❑ 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 On SIONATUREI LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY# TANK# STATE 01 PERMIT NUMBER PERMIT APPROVED BYIDATE PERMIT EXPIRATION DATE THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORMA HAS BEEN FILED. FORM C MUST BE COMPLETED FOR INSTALLATIONS.THIS FORM SHOULD BE ACCOMPANIED BY A PLOT PL"' FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE I—CFIGROUND STORAGE TANK REGULATIONS FORM B (6.95) 3 ' 6 0 /` ./I y �9 � `�