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'v STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD .y"� 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 INFORMATION7 PERMANENTLY CLOSED ONSITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE Nw< S TANK REMOVED 10 GS DBA OR FACILITY NAME WHERE TANK IS INSTALLED: IC +" 1 a I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A OWNER'S TANK I.D.If VA B. MANUFACTURED BY: C. DATE INSTALLED(MOMAY/YEAR) 4 D. TANK CAPACITY IN GALLONS: S VVV II.TANK CONTENTS IF A-1 IS MARKED,COMPLETE ITEM C. A 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C. to REOVIAR UNLEADED ❑ 3 DIESEL ❑ S AVIATIONGAS ❑ 2 PETROLEUM ❑ BO EMPTY ❑ 1 PRODUCT ❑ 1E PREMIUM UNLEADED ❑ 4 GASAHOL ❑ 7 METHANOL Ic MIDGRADE UNLEADED 5 JET FUEL ❑ S MBS ❑ 3 CHEMICALPRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED 89 OTMER(DESCRIBE M IRBA D.BaOM D. IF(At)IS NOT MARKED, ENTER NAME OF SUBSTAGE STORED C.A.S.M III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A B.AND C.AND ALL THAT APPLIES IN BOX D AND A. TYPE Of r0 Iy11 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 5 INTERNAL BLADDER SYSTEM ❑ 95 UNKNOWN SYSTEM1^J 2 SINGLE WALL ❑ 4 SINGLE WALL IN A VAULT ❑ 99 OTHER B. TANK 1 BARE STEEL ❑ 2 STAINLESS STEEL e95 GLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ S POLYVINYL CHLORIDE INUM ❑ B 100% METHANOL COMPATIBLE W/FRP (Primary Tmk) ❑ 9 BRONZE ❑ 10 GALVANIZED STEELNOWN ❑ 99 OTHER C.INTERIOR ❑ 1 RUBBER UNED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING LINING OR ❑ 5 GLASS LINING 5 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 10D% METRA 7 YES- NO- D.EXTERIOR ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC CORROSION PROTECTION ❑ S CATHODIC PROTECTION 91 NON ❑95 UNKNOWN ❑ 99 OTHER E.SPILL AND OVERFILL, SPILL CONTAINMENT INSTALLED TY ) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) de, DROP BE YES_ NO STRIKER PLATE YES_ NO_ DISPENSER CONTAINMENT YES_ NO IV.PIPING INFORMATION CIRCLE A IF ABOVE/ROUND OR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION 2 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER S. CONSTRUCTION 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 U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL W/COATING A U B 100% METHANOL COMPATIBLE WIFRP PROTECTION A U 9 GALVANIZED EL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION ❑I qUNEO2 �sO99 SER QM¢��oT V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK 2 RECONAL CILIATION CILIATIONORY ❑ 3 VADOZE MONITORING 4 CU�ITOING TANK ❑S GROUND WATER ❑ B ANNUALTESTING ❑ 7 MON INUTOROG INTERSTITIAL 8 SIR ❑ B TANKLY MANUAL E::] 10 MONTHLY TANK ❑ 95 UNKNOWN ❑ 99 OTHER G TESTING VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) 1.ESTIMn L441 (MOIDAY/YR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH VES ❑ NO SUBSTAGE REMAINING GALLONS INERT MATERIAL? THIS FORM HAS BEEN COMPLETED UNDER PEN F P JURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND qoRRECT TANK OWNER'S NAMEA DAT�n ^ /� (PRMFO K= SIGNATURE)J' '7� I�1 l, ✓ "I LOCAL AGENCY USE ONLY -THE STATE LD.NUMBER IS COMPOSED OF THE FOUR UMBERS BELOW 22'c 'b / COUNTY* JURISDICTION N FACILITY N TANK M STATE I.D:# PERMIT NUMBER PERMIT APPROVED BYIDATE PERMIT EXPIRATION DATE f�4-14 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 PI•N. FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE 11u0ERGROUND STORAGE TANK REGULATIONS FORM 0 (6.95) J 0-3 -q 7 �1�46