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STATE OF CALIFORNIA a STATE WATER RESOURCES CONTROL BOARD s mom, Y UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B ;A I COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ONE TEMRMIT ❑ 6 TEMPORARY TANK CLOSURE '1�' B TANK REMOVED ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PEF� (• 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. A. ❑ 1 MOTOR VEHICLE FUEL !4 OIL B. C. to REGUTAA UNLEADED 3 DIESEL ❑ 6 AVIATION OAS ❑ 2 PETROLEUM //❑"" 80 EMPTY ❑ 7 PRODUCT ❑ 1D PPEMNM UNLEADED 4 GASAHOL ❑ 7 METHANOL ❑ Ic MIDGPADE UNLEADED ❑ 5 JET FUEL ❑ B MBS ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN 2 WASTE ❑ 2 LEADED ❑ 99 OTHER(DESCRIBE IN ITEM D.BELOM 0. IF(At)IS NOT MARKED. ENTER NAME OF SUBSTANCE STORED C.A S.k III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A B,AND C.AND AUVKAT APPLIES IN BOX D AND E A. TYPE OF .❑�/I DOUBLE WALL ❑ 3 SINGLE WALL WITH 1 O LINER ❑ 5 INTERNAL BLADDER SYSTEM ❑ 95 UNKNOWN SYSTEM I�X2 SINGLE WALL F-14 SINGLE WALL IN A V LT ❑ 99 OTHER B. TANK ; MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHL IDE ❑ ] ALUMINUM ❑ B 100% METHANOL COMPATIBLE W/FRP (PftMY T-k) ❑ 9 BRONZE ❑ 10 GALVANIZED EEL ❑ 95 UNKNOWN ❑ 99 OTHER C.INTERIOR ❑ I RUBBER LINED �❑—y2 ALKYD LINI ❑ 3 EPDXY UNING ❑ 4 PHENOLIC LINING LINING OR ❑ 5 GLASS LINING IXI S UNUNED ❑ 95 UNKNOWN ❑ 99 OTHER COATING IS LINING MATERIAL COMPATIBLE 10D% ME ANOL7 YES_ NO—X D.EXTERIOR ❑ I POLYETHYLENE WRAP ❑ 2 COATI ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC CORROSION PROTECTION ❑ 5 CATHODIC PROTECTION 91 NON ❑95 UNKNOWN ❑ 99 OTHER E SPILL AND OVERFILL,810. SPILL CONTAINMENT INSTALLED(Y R) OVERFILL PREVENTI UIPMENT INSTALLED(YEAR) DROP TUBE VES_ NO STR ER PLATE YES_ NO DISPENSER CONTAINMENT YES_ NO IV.PIPING INFORMATION CIRCLE A IF ABOVE GR UNOOR U IF UNDERGROUND.BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION A U PRESSURE A p GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION Ao SINGLE WALL A U 12 DOUBLE WALL A U 3 UNED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND AMM I BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A U 4 FIBERGLASS PIPE QQRRQgIQN ' 5 ALUMINUM A U B CONCRETE A U 7 STEEL W/COATING A U 8 IDD% 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 ❑I IECK�Mcu uxE IFAIf ❑2 LNE s9 ❑3 IK)NTmws NIEASTRML ❑4 ELEcmoBK uraE ❑5 A9roMAn0 n ❑ 99 OTHER aETEaoR NDNTGRN3 vNc aElE U smnwx9 V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 RECNUAL ONCIUATIONORY ❑ 3 MONIITORING OZE ❑ 4 GAUGING NG AUTOMATIC TANK ❑5 GROUNDTORING�R ❑ B TESTINGTANK ❑ 7 R NCOONNNUOI'UUSINTERS ITIA- ❑ 9 SIR ❑ 9 TANKLY MANUAL ❑10 MOT NG HLY TANK ❑ 95 UNKNOWN E:]99 OTHER VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) 1.ESTIMATE DA USE MO'DAYNP) 2.ESTIMATED OUANTITY OF �i(` 3.WAS TANK FILLED WITH YES ❑ NO SUBSTANCE REMAINING �J GALLONS INERT MATERIAL 7 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 IPRNTED 6 SIGNATURE) LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY M TANK# STATE I.D.# PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE 1; AA77 ma 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 STORAGES TANK REGULATIONS FORM 8 (6.95) g /) /3- 1 I 4,"