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STATE OF CALIFORNIA p�youAc;s c STATE WATER RESOURCES CONTROL BOARD ¢ p+4 UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B s - COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM, MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLCS b ON SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED; I, TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A OWNER'S TANK L D-S B. MANUFACTURED BY: C. DATE INSTALLED(MO/DAY/YEAR) o 1 D. TANK CAPACITY IN GALLONS: df�C c c- II.TANK CONTENTS IF A-1 IS MARKED,COMPLETE ITEM C. r 1 A, ❑ 1 MOTOR VEHICLE FUEL ❑ 4 OIL B, C ❑ is REGULAR UNLEADED ❑ 3 DIESEL ❑ 6 AVIATION GAS ❑ 2 PETROLEUM ❑ BO EMPTY ❑ 1 PRODUCT ©f lb PREMIUM UNLEADED ❑ 4 GASAHOL ❑ 7 METHANOL Ll 1c MIDGRADE UNLEADED ❑ 5 JET FUEL ❑ 8 M55 F-13 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED- ❑ 99 OTHER.(DESCRIBE IN ITEM D.BELOW) D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED CAS 0: 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 0 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 0 99 OTHER 8. TANK ❑ 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS 4 STEEL CLAD WI FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLEWIFRP (PTimaryTank) ❑ 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 100% METHANOL? YES_ NO— D.EXTERIOR ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑:4 FIBERGLASS REINFORCED PLASTIC CORROSION PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE ❑95 UNKNOWN ❑ 99 OTHER E.SPILL AND OVERFILL,010. SPILL CONTAINMENT INSTALLED(YEAR} OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) DROP TUBE YES NL' NO STRIKER PLATE YES _ NO DISPENSER CONTAINMENT YES " NO IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION A JJ 2 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 i BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A tU l4 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL W/COATING A U 8 10C% METHANOL COMPATIBLE W1FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHCOIC PROTECTION A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION ❑1 MECHANICAL LINE LEAK 2 UN£TIGHTNESS E:]3 CONTINUOUS INTERSTITIAL 4 ELECTRONIC LINE ^1 5 AUTOMATIC PUMP ❑ DETECTOn L_J TESTING MONITORING ly LEAK DETECTOR IJ SHUTDOWN 99 OTHER V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 RECONCILMANUAL IATION ❑ 3 MOORING ❑ 4 GAUGING MONITORING TANK ❑ 5 MOONTORINGTER ❑ 6 ANNUAL TESTI NG 7 CONTINUOUS MONITORING INTERSTITIAL ❑ B SIR ❑ 9 TANK GAUGING WEKLY ❑ 10 TESTINGY TANK ❑ g5 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) 1.ESTIMATED DATE LAST USED(MOIDAYNR) 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 (PRINTED 8 SIGNATURE( c LOCAL AGENCY USE ONLY THE STATE P.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY If TANK# STATE I.D.# A 31I - Hai= PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE - - 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) - .