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STATE OF CALIFORNIA •sw•ee• i STATE WATER RESOURCES CONTROL BOARD o UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B �� =^ .A COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY O 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION a ] PERMANENTLY CLOSED ON SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE O 8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: p I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A OWNER'S TANK 1.0.# Z S. MANUFACTURED BY:�OQ��dA w� C. DATE INSTALLED(MODAYNEAR) e? D. TANK CAPACITY IN GALLONS: II.TANK ••NKKK�/CONTENTS IFA-11S MARKED.COMPLETE ITEM C. A U MOTOR VEHICLE FUEL ❑ 4 OIL B. C. to REGULAR UMEAD® 3 DIESEL ❑ 8 AVIATIONGAS 10 PREAIMN UNLEADED { GASAHOL ❑ ] METHANOL 2 PETROLEUM ❑ BO EMPTY I PRODUCT ❑ fe NOGPAOE UNLEADED 5 JET FUEL ❑ 8 MBS ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN 2 WASTE a 2 LEADED H 99 OTHE MESCRIBEINREMD.BEOM D. IF(A 1)IS NOT MARKED, ENTER NAME OF SUBSTANCE 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 cy—I DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 5 INTERNAL BLADDER SYSTEM ❑ 95 UNKNOWN SYSTEM ❑ 2 SINGLE WALL Q 4 SINGLE WALL IN A VAULT ❑ 99 OTHER 8. TANK ❑ I BARE STEEL Q 2 STAINLESS STEEL ❑ 3 FIBERGLASS 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE O 6 POLYVINYL CHLORIDE ❑ ] ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP (PHmsry Tank) ❑ 9 BRONZE O 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER C.INTERIOR ❑ 1 RUBBER LINED ❑ 2 ALKYD UNING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING LINING OR O 5 GLASS LINING 6 UNLINED ❑ -95UNKNOWN ❑ 99 OTHER COATING IS LINING MATERIAL COMPATIBLE'WITH 100% METHANOL? YES-A /NO_ D.EXTERIOR ❑ 1 POLYETHYLENE WRAP a 2 COATING ❑ 3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC CORROSION PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER E.SPILL AND OVERFILL,ex. SPILL CONTAINMENT IN ALLED(YEAR) OVERFILL P ENTION EQUIPMENT INSTALLED(YEAR) DROP TUBE YES NO_ STRIKERPLATE YES_ NO DISPENSER CONTAINMENT YES NO_ IV.PIPING INFORMATION CIRCLE A IFABOVEGROUNDOR U IFUNOERGROUNO.SOTHIFAPPUCA8LE 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 A U 1 SINGLE WALL A 2 DOUBLE WALL A U 3 LINED TRENCH A U 9S UNKNOWN A U 99 OTHER C. MATERIAL AND A U 1 BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) 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 A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION 1 K[eKTmOu lata IFAK [:]2I n6KDEM 3 mKnxuous NrBLmIUL A MEerAOKIe uxE s AuroNene wM• nEiECRXV TES 1bNi06NG ❑ LEAK LfElEm011 ❑ 9Am%1WN ❑ 99 OTHER V.TANK LEAK DETECTION I VISUAL CHECK ❑ 2 RECONCILIATIONANUAL ORY ❑ 3 MAONNIITORING ❑ 4 ALITOMATGAUGING MONITORING TANK O 5 MGROUND WATERONITORING ❑ 8 TESTIINGTANK ] MONITORING INTERSTITIAL 71 8 SIR ❑ 9 WE .ALy NAL ❑10 GMONTHLY TANK O 95 UNKNOWN ❑ 99 OTHER STIN VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) 1.ESTIMATED DATE LAST USED(MO/DAYNR) 2.ESTIMATED OUANTTY OF I 3.WAS TANK FILLED WITH YES ❑ NO❑ SUBSTANCE REMAINING 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 OWNERS NAME GATE (PBWT.aSIG 'A.) LOCAL AGENCY USE ONLY THE STATE L0.NUMBER IS COMPOSED OFTHE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY# TANK k STATE 04 ® 0 7 g��$ PERMIT NUMBER PERMIT APPROVED BVA]ATE PERMIT EXPIRATION DATE THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORMA 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 STORAGE TANK REGULATIONS FORM 8 (6-95) /i _ ( L, _ ,/ ,