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STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD a 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 CLOSED ON SITE ONE REM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED 0 t DBA OR FACILITY NAME WHERE TANK IS INSTALLED: p T I. TANK DESCRIPTION COMPLETE ALL ITEMS— SPECIFY IF UNKNOWN A OWNER'S TANK I.D.Y Z B. MANUFACTURED BY:��Q /I C. DATE INSTALLED(MOIDAYNEAR) D. TANK CAPACITY IN GALLONS: pOD II.TANK,, //CONTENTS IF A-1 IS MARKED,COMPLETE ITEM C. ' A. 9!51 MOTOR VEHICLE FUEL ❑ 4 OIL B. C. 1a REGULAR UNLEADED O 3 DIESEL ❑ 6 AVIATION GAS u^' ,�y(/ 1C PREMIUM UNLEADED ❑ 4 GASAHOL ❑ 7 METHANOL 2 PETROLEUM ❑ 80 EMPTY 1 PRODUCT ❑ 3 CHEMICALPRODUCT ❑ 95 UNKNOWN 2 WASTE ❑ 2 LEADEMIDGRAD UNLEADED ❑ 5 JET ER(D ❑ 8 EMD ❑ 2 LEADED ❑ 88 OTHER(DESCRIBE M REM D.BELOVtf D. IF(A1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A S.e: 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 I DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 5 INTERNAL BLADDER SYSTEM O 95 UNKNOWN SYSTEM E 2 SINGLE WALL ❑ 4 SINGLE WALL IN A VAULT ❑ 99 OTHER B. TANK ❑ 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS 4 STEEL CLAD W1 FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 8 POLYVINYL CHLORIDE ❑ 7 ALUMINUM 8 100% METHANOL COMPATIBLE WIFRP (POMMY Tan'J ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER C.INTERIOR ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING LINING OR ❑ 5 GLASS LINING 6 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 10046 METHANOL? YESAZNO— D.EXTERIOR F__11 POLYETHYLENE WRAP E] 2 COATING ❑ 3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC CORROSION PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE ❑95 UNKNOWN ❑ 99 OTHER E.SPILL AND OVERFILL,aTC. SPILL CONTAINMENT IN LLED(YEAR) OVERFILL P ENTION EQUIPMENT INSTALLED(YEAR) DROP TUBE VES_ NO_ STRIKER PLATE YES NO DISPENSER CONTAINMENT YESNO IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION Aft PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL A 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) FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL W/COATING A U 8 100% METHANOL COMPATIBLE WIFRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION E 1 MECHANICAL UNE LEN( O 2 UNE TIGNTNEES O 3 COWINUWS NTERSi E]4 EMOTiW14C IRE O 5 AIRCWRC PUMP ❑ 99 OTHER [XTECTOR TESTING MORTORING LAN GETELT011 91UTGOVM V.TANK LEAK DETECTION 1 VISUAL CHECK ❑ 2 RECONCIL ATIONMANUAL INVENTORY ❑ 3 MONIITORING VAOZE ❑ 4 AUTOMATIGAUGING C TANK ❑ 5 MON TORINGTER O 6 TEGROUNDWASTINGTANN 7 MONITORING CONTINUOUSINTERSTITIAL ❑ e SIR ❑ 9 T NKIGAUGNG L ❑10 TESTINGY TANK E—] 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PUCE) 1.ESTIMATED DATE LAST USED(MOMAYIYR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES ❑ NO ❑ SUBSTANCE REMAINING GALLONS INERT MATERIAL? 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 d SIGNgTURE) LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY k JURISDICTION# FACILITY 0 TANK k STATE I.Dl Kff I I I 1 = Lo5_L* PERMIT NUMBER PERMIT APPROVED BYMATE PERMIT EXPIRATION UATE 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 STORAGE TANK REGULATIONS FORM B (6-95)