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STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD uyd� 8 UNDERGROUND STORAGE TANK PERMIT APPLICATION • FORM B COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY F-1 I NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION7 PERMANENTLY CLOSED ONSIIE ONE ITEM F-12 INTERIM PERMIT F--] 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE S 1TANK REMOVVE,Dct ,� — DBA OR FACILITY NAME WHERE TANK IS INSTALLED: , Sfoc I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A OWNERS TANK 1.D. / B. MANUFACTURD BY: C. DATE INSTALLED(MO/DAYNEAR) D. TANK CAPACITY IN GALLONS: D II.TANK CONTENTS IF A•1 IS MARKED,COMPLETE ITEM C. �'1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C. to REGULAR UNLEADED O 3 DIESEL ❑ S AVIATION GAS A ❑ 1E PREMIUM UNLEADED o 4 GASAHOL O 7 METHANOL 2 PETROLEUM ❑ 60 EMPTY W I PRODUCT ❑ 1a MIDGRADE UNLEADED O 5 JET FUEL ❑ B W5 ❑ 3 CHEMICALPRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE 2 LEADED ❑ 88 OTHER(059CflBEN REM D.BELOVrf D. IF(A7)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A S.N III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.B.AND C,AND ALL THAT APPLIES IN BOK 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 F72 STAINLESS STEEL F-13 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL fir❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ a 100% METHANOL COMPATIBLE W/FRP (PHmM T"N ❑ 9 BRONZE ❑ /0 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER C.INTERIOR ❑ 1 RUBBER LINED �❑ 2 ALKYD LINING ❑ 3 EPDXY UNING ❑ 4 PHENOLIC LINING LINING OR ❑ 5 GLASS LINING 170 6 UNUNED ❑ 95 UNKNOWN ❑ 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES— NO-A D.EXTERIOR ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC CORROSION PROTECTION ❑ 5 CATHODIC PROTECTION 81 NONE ❑94 UNKNOWN ❑ 99 OTHER SPILL CONTAINMENT INSTALLED R) OVERFILL PREVENTI OUIPMENT INSTALLED(YEAR) E.SPILL AND OVERFILL,9TC. DROP TUBE YES_ NO STRIKER PLATE YES_ NO DISPENSER CONTAINMENT NO IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND.BOTH IF APPUCABLE A. SYSTEM TYPE A V 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION A(&M SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND A I BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A U 4 FIBERGLASS PIPE CORROSION A 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL W/COATING A U B IOD% METHANOL COMPATIBLE W/FRP PROTECTION A U B GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION ❑1 =M=Mff uAK ❑2 UNEn W Q 3 uoxoaNT��BTEreTmM E4' ul� s A nv 99 OTHER V.TANK LEAK DETECTION ❑ I VISUAL CHECK 2 RECONCILIATION RY ❑ 3 VADOZMONIDRING ❑ 4 GAU7OGING C TANK O 5 GROUND WATER ❑6 TESTNCTANK 7 MON TORO INTERSTITIAL 6 SIR 6 WEEK ALAURINGAL ❑10 MONTHLY TANK ❑ 95 UNKNOWN ❑99 OTHER VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) 1.ESTIYATED DATE LAST USED(MO/DAY/YR) 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 a SIGNATURE) LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELovr3 COUNTY# JURISDICTION N FACILITY# TANK# STATE I.D.# 0 I 11- PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE !UA4 j C MUST BE FOR THIS FORM MUSTSHOULD BE ACCOMPANIED PBY AI LOTPICATIOILEFORM A,UNLESS A CURRENT FORM A HAS BEEN FILED.THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THF i RGROUND COMPLETED TORMRA EEE�TANK REGULATIONS THIS �M FORM B (6-95) +