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STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD c o 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 C ONE REM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE B TANK REMOVED O DBA OR FACILITY NAME WHERE TANK IS INSTALLED: ��q I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A OWNER'S TANK I.D.# TK 3.. B. MANUFACTURED BY: C. DATE INSTALLED(MOIDAWYEAR) � D. TANK CAPACITY IN GALLONS: II.TANK CONTENTS IF A-1 IS MARKED,COMPLETE ITEM C. A. 1 MOTOR VEHICLE FUEL 040'L 4OIL Ber.,/ C, is REGULAR UNLEPDED 3 DIESEL ❑ 8 AVIATION GAS ❑ 2 PETROLEUM ❑ 80 EMPTYVii PRODUCT 1b PREMIUM UNLEADED 4 GASAHOL ❑ 7METHANOL -- ❑ is MIDGNADE UNLEADED nT�-- 5 JETFUEL E::] 8 M85 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED u 99 OTHER(DFSCRIBE M ITEM D.BB.OM D. IF(At)IS NOT MARKED. ENTER NAME OFSUBSTANCE 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 ❑ 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 5 INTERNAL BLADDER SYSTEM ❑ 95 UNKNOWN SYSTEM 2 SINGLE WALL ❑ 4 SINGLE WALL IN A VAULT ❑ 99 OTHER B. TANK I BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD N FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100°6 METHANOL COMPATIBLE WIFRP (Pd-9Y T9 k) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER C.INTERIOR ❑ I RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOUC LINING LINING OR ❑ 5 GLASS LINING 6 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 100,6 METHANOL? YES_ NOX D.EXTERIOR ❑ I POLYETHYLENE WRAP2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC CORROSION PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE E:] 95 UNKNOWN ❑ 99 OTHER E.SPILL AND OVERFILL,BSO. SPILL CONTAINMENT INSTALLED(YEAR) OVERRLL PREVENTIOQ EOUIPMENT INSTALLED(YEAR) DROP TUBE YES NO SZ STRIKER PLATE YES NO DISPENSER CONTAINMENT YES_ NO IV.PIPING INFORMATION CIRCLE A IF ABOVEGROUND OR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U I SUCTION A&2 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER S. CONSTRUCTION A01 1 SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND AOI 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 N COATING A U 8 100% METHANOL COMPATIBLENFRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION Wl MEcxunaL LPE LFAK 2 UM TIGHTa 3 caxnxudrs MTNSnnAL 4 REMMIC UI E 5 AuroMAnc Pu6w ❑ oETECfd1 ❑ TE3nx0 ❑ MDNTDeixa ❑ LTAx 9ETEcroR ❑ 9Mr0owx 99 OTHER V.TANK LEAK DETEC ON ❑ 1 VISUAL CHECK 2 RECOMANUNCILIATIONAL ORV ❑ 3 MONOITORING ZE ❑ 4 GAUGING AUTOMATIC TANK ❑ 5 MONITORINGGROUND TER aANNUNGTANN ❑ 7 MONTHUOUS NG INTERSTITIAL B SIR ❑ 9 WEEKLY MANUAL ❑10 MONTHLYTESTING TANK ❑ 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) 1.ESTIMATED TE LAST USED(M V ) 2 ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH SUBSTANCE REMAINING GALLONS INERT MATERIAL? YES ❑ NO 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 8 31GNATUREI LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW Q STATE 04COUNTY# JURISDICTION# FACILITY# TANK# QQ PERMIT NUMBER PERMIT APPROVED BYIDATE PERMIT EXPIRATION DATE iI I J 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" FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE P-'-AGROUND STORAGE TANK TANKREGULATIONS FORMS (6-95) �LV- g yy /