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STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD 3A ' UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B I y� COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY OSED ON S E ONE ITEM 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOV DBA OR FACILITY NAME WHERE TANK IS INSTALLED: I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A OWNERS TANK 1.D.# S. MANUFACTURED BY: C. DATE INSTALLED(MO/DAYNEAR) D. TANK CAPACITY IN GALLONS: II.TANK CONTENTS IF A-1 IS MARKED,COMPLETE ITEM C. A1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C. EllaREGULAR UNLEADED ❑ 3 DIESEL ❑ 6 AVIATION GAS �2 PETROLEUM ❑ 80 EMPTY 1 PRODUCT ❑ 1b PREMIUM UNLEADED ❑ 6 GASAHOL ❑ ] METHANOL ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 8 M85 LQ 2C MIIDDGRADE UNLEADED DED 0 99J TIER(DESlFUELO IN ITEM D.BFLOVA D. IF(A7)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A S.It: 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 W/FIBERGLASS REINFORCED PLASTIC MATERIAL 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP (p6nq TMk) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER C.INTERIOR ❑ i RUBBER UNED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING LINING OR ❑ 5 GLASS LINING 6 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER COATING IS LINING MATERIAL COMPATIB WITH 100% METHANOL? YES_ NO_ D.EXTERIOR ❑ 1 POLYE 14YLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC CORROSION PROTECTION ❑ 5 CATHODIC PROTECTION 91 NONE E::]95 UNKNOWN ❑ 99 OTHER E SPILL AND OVERFILL,MO. SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) DROP TUBE YES_ NO_ STRIKER PLATE YES_ NO_ DISPENSER CONTAINMENT YES NO IV.PIPING INFORMATI N CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLEPIPING A U 99 OTHER B. CONSTRUCTION A i 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 ] STEEL W/COATING A U 8 100% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A4)95 UNKNOWN A U 99 OTHER D. LEAK DETECTION1 Ia:cKAMat U"tFAK 2 ME Mw W M IWERSm 4 EUMQIc UHE 5 AUM11C PULP ❑ OflEGTaR ❑ TES9Na ❑3 Can MOMTO3Rp ❑ IEYI UETECMR ❑ SHUTI m ❑ 99 OTHER V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 RECONCILIATION MANUAL ORV ❑ 3 MONITORING ❑ 4 GAUGINAUTOMATG MONITORING TANK ❑ 5 MONTORINGGROUND �R ❑ 6 TESTING ANNUAL TANK VADOZE ❑ 7 MON TORO INTERSTITIAL ❑ 8 SIR ❑ 9 TANEXGLY NGAL ❑10 TE NTTINGY TANKEja 95 UNKNOWN ❑99 OTHER VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PUCE) 1.ESTIMATED!=ED USED(MO/DAY/YR) 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 On 61ONATURE7 LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY tl q TANK M OO STATE I.D.# p p �v PERMIT NUMBER PERMIT APPROVED BY/DATE PERMT EXPIRATION DATE THIS FORM MUST BE ACCOMPANIED BYA PERMIT APPLICATION-FORMA,UNLESS A CURRENT FORMA HASBEENFILED. FORM C MUST BE COMPLETED FOR INSTALLATIONS THISFORM SHOULD BE ACCOMPANIED BY A PLOT P FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE -RGROUND STORAGE TANK REGULATIONS FORMS (695) `/