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• �� \/ STATE OF CALIFORNIA �c'� STATE WATER RESOURCES CONTROL BOARD +d� .,m o UNDERGROUND STORAGE TANK PERMIT APPLICATION -FORM B 's, ,., I COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT O 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION T PERMANENTLY CLOSED 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 A, OWNER'S TANK I.D.♦ B. MANUFACTURED BY: C. DATE INSTALLED(MO/DAYNEAR) D. TANK CAPACITY IN GALLONS: II.TANK CONTENTS IF A-1 IS MARKED,COMPLETE ITEM C. ❑ to REGULAR UNLEADED ❑ 3 DIESEL ❑ 6 AVIATION GAS A. ❑ 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C' ❑ 1b PREMIUM UNLEADED O 4 GASAHOL ❑ T METHANOL ❑ 2 PETROLEUM ❑ 80 EMPTY ❑ 1 PRODUCT ❑ is MIDGRADE UNLEADED 5 JET FUEL ❑ 8 M85 ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN �2 WASTE ❑ 2 LEADED 99 OTHER(DESCRIBE IN ITEM D.BELOW) D. IF(A/)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED (,() S C.A.S.ow 05 III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A,S.AND C,AND ALL THAT APPLIES IN BOX D AND E A. TYPE OF ❑ 1 DOUBLE WALL F-] 3 SINGLE WALL WITH EXTERIOR LINER ❑ 5 INTERNAL BLADDER SYSTEM ❑ 95 UNKNOWN . SYSTEM 192 SINGLE WALL ❑ 4 SINGLE WALL IN A VAULT ❑ 99 OTHER B. TANK 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ T ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER C.INTERIOR ❑ 1 RUBBER UNED ❑ 2 ALKYD UNING ❑ 3 EPDXY LINING 4 PHENOLIC LINING LINING OR ❑ 5 GLASS LINING X6 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NOX D.EXTERIOR 1 POLYETHYLENE WRAP F-� 2 COATING ❑ 3 VINYL WRAP E] 4 FIBERGLASS REINFORCED PLASTIC CORROSION PROTECTION ❑ 5 CATHODICPROTECRON 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER E SPILL AND OVERFILL,lCC. SPILL CONTAINMENT INSTALLED,(YFAR) OVERFILL PREVENTIWOUIPMENT INSTALLED(YEAR) DROP TUBE YES_ NO�-_ ER PLATE YES_ NO DISPENSER CONTAINMENT YES_ NO_ IV.PIPING INFORMATION CIRCLE A IFABOVEGROUNDOR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION A Lu 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 5 ALUMINUM A U 0 CONCRETE A U T STEEL W/COATING A U B 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. LEAK DETECTION 1 MECNN4CAL LINE LEAK 2 LNE TBHTNESS 3 CONTINLWS NTEASTIILLL 4 EIEEIRONIC UNE 5 AUTOMATIC PULPNA ❑ CEIECTOR ❑ TES11N0 ❑ MCMTWMC ❑ TAN CEIECTOR ❑ 91UmOWN Unk99 OTHER V.TANK LEAK DETECTION ❑ / VISUAL CHECK ❑ 2 RECONCILATIONNUAL INVENTORY ❑ 3 MONIITORING OZE ❑ 4 AUTOMATGAUGING MONITORING TANK TING ..,,❑—,//5 GROUND WATER ❑ 6 TESTING ❑ T CONTINUOUS INTERSTITIAL ❑ 8 SIR ❑ 9 TANK LY MANUAL ❑10 MONTHLY TANK tyI 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) / 1.ESTIMATED DATE LAST USED AV/YR) 2.ESTIMATED OUANTITY OF 3.WAS TANK FILLED WITH YES ❑ NO la 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 A SIGNATURE) 1 7771 LOCAL AGENCY USE ONLY THE STATE LD.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW 0060 COUNTY N JURISDICTION M FACILITY a TANK a STATE I.D.# PERMIT NUMBER PERMIT APPROVED SY/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 PLAN. FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STOR///AAyyyyyyGE TANK REGULATIONS FORM B (6.95) / 6)— / y w