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• STATE OF CALIFORNIA %Wd STATE WATER RESOURCES CONTROL BOARD i' g 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 REM ❑ 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 Cj A OWNER'S TANK I.D.If B. MANUFACTURED BY: C. DATE INSTALLED(MO/DAV/YEAR) D. TANK CAPACITY IN GALLONS: II.TANK CONTENTS IFA-1 IS MARKED.COMPLETE ITEM C. A. �, 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C, to REGUL4R UNLEADED O 3 DIESEL ❑ 6 AVIATIONGAS ❑ 2 PETROLEUM O 80 EMPTY �1 PRODUCT ❑ ib PREMIUM UNLEADED j 4 GASAHOL ❑ 7 METHANOL ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ Ic MIDGRADE UNLEADED nI� g JET FUEL ❑ 8 M85 ❑ 2 LEADED u 99 OTHER WORSE W ITEM D.BELOW) D. IF(A1)IS NOT MARKED. ENTER NAME OF SUBSTANCE STORED C.A.S.a III. TANK CONST TION MARK ONE ITEM ONLY IN BOXES A,B,AND C.AND ALL THAT APPLIES IN BOX D AND E A. TYPE OF ❑ DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 5 INTERNAL BLADDER SYSTEM ❑ 95 UNKNOWN SYSTEM ❑ SINGLE WALL ❑ 4 SINGLE WALL IN A VAULT ❑ 99 OTHER B. TANK ❑ ' ARE EL ❑ 2 STAINLESS STEEL F__] 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL El5 CONCR ❑ B POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLEW/FRP (Primary Tank) ❑ 9 BRONZE O 10 GALVANIZED STEEL ❑ 95 UNKNOWN Q 99 OTHER C.INTERIOR ❑ 1 RUBBER UNED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING 4 PHENOLIC LINING LINING OR F-15 GLASS LINING 8 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER COATING IS LINING MATERIAL COMPATIBLE TH 100% METHANOL? VES_ NO— D.EXTERIOR ❑ 1 POLYETHYLENE WRAP COATING F-13 VINYL WRAP E] d FIBERGLASS REINFORCED PLASTIC CORROSION PROTECTION ❑ 5 CATHODIC PROTECTION ED--] 91 N ❑ 95 UNKNOWN ❑ 99 OTHER E.SPILL AND OVERFILL,BTC. SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) DROP TUBE YES NO_ IKER PLATE YES_ NO_ DISPENSER CONTAINMENT VES_ NO IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR 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 T DOUBLE WALL Ai) U 3 LINED TRENCH A U BE UNKNOWN A U 99 OTHER C. MATERIAL AND A U 1 BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(WC)A U 4 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U STEEL W/COATING A U 8 100%METHANOL COMPATIBLE WA=RP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A UNKNOWN A U 99 OTHER D. LEAK DETECTION t MLGWAGL uN LFAIc 2 uM m4rtx9u 3 c9Nrwuous artERsrmu 4 ELE oxlc uxE 5 A9mhIA=Puw ❑ OE1ELiOB ❑ TEafNG ❑ NONTORNO ❑ IEAa CTOR ❑ 911R90WH ❑ 99 OTHER V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 MANUAL IIATIONNVENTORY ❑ 3 MONITORING ❑ 4 GAUGING MONITORING TANK E::] 5 GROUND MON TORINGTER ❑S TANK ❑ 7 CONTINUONU(aS INTERSTITIAL ❑ B SIR ❑ 9 WEEKLY E K LY MANGAL E]10 MOSNTHLY TING TANK ❑ 95 UNKNOWN E]99 OTHER VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PUCE) 1.ESTIMATED DATE LAST USED AY/YR) 2.ESTIMATED QUANTITY OFn3.WAS TANK FILLED WITH VES ❑ NO G SUB STANCE 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 OWNERS NAME DATE (PRINTED d SKiNAm1RE) LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY k JURISDICTION# �-�--FACILITY N TANK H STATE I.D.4 I PERMIT NUMBER PERMIT APPROVED BYIDATE PERMIT EXPIRATION DATE dD q� THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORMA HAS BEEN FILED. FORM C MUST BE COMPLETED FORINSTALLATIONS.THIS FORM SHOULD BE ACCOMPANIED BY A PLOT PL' `ILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE I"--RGROUND STORAGE TANK REGULATIONS FORMS (6-95) `� " FORD034&RT