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STATE OF CALIFORNIA ` w,.. STATE WATER RESOURCES CONTROL BOARD "`� UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B "`®' COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. ��"'"""�" MARK ONLY ❑ 1 NEW PERMIT O 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ON SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE a 8 TANK REMOVED I V DBA OR FACILITY NAME WHERE TANK IS INSTALLED: L TANK DESCRIPTION COMPLETE ALL ITEMS— SPECIFY IF UNKNOWN A OWNERS TANK I.D.1 B. MANUFACTURED BY: C. DATE INSTAUED(M(YDAY/NEAR) (/-� D. TANK CAPACITY IN GALLONS: � IL TANK CONTENTS IF A-1 IS MARKED,COMPLETE ITEM C. A 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C. la REGULAR UNLEADED 3 DIESEL ❑ 6 AVIATINGAS 2 PETROLEUM ❑ 80 EMPTY PRODUCT ❑ 1b PREMIUM UNLEADED 4 GASAHOL ❑ 7 METHANOL ❑ 10 MIDGNADE UNLEADED n`� 5 JET FUEL ❑ 8 MBS ❑ 3 CHEMICAL PRODUCT ❑ B5 UNKNOWN 2 WASTE LEADED u 99 OTHER (DESCRIBE N REM D.BaOYQ D. IF(A i)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A S.R 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 ❑ 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 5 INTERNAL BLADDER SYSTEM UNW40WN SYSTEM ❑ 2 SINGLE WALL ❑ 4 SINGLE WALL IN A VAULT ❑ 99 OTHER B. TANK I BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ B 100% METHANOL COMPATIBLE W/FRP (PriMoy Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN O 99 OTHER C.INTERIOR ❑ I RUBBER LINED ❑ 2 ALKYD LINING Q 3 EPDXY LINING ❑ 4 PHENOLIC LINING LINING OR ❑ 5 GLASS LINING ❑ 8 UNLINED �95 UNKNOWN ❑ 99 OTHER COATING 18 LINING MATERIAL COMPATIBLE WITH IDD% METHANOL? 'YES_ NO— D.EXTERIOR ❑ I POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC CORROSION PROTECTION ED S CATHODIC PROTECTION ❑ 91 CNE UNKNOWN ❑ 99 OTHER E.SPILL AND OVERFILL,of. SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) DROP TUBE YES_ NO_ STRIKER PLATE YES_ C_ DISPENSER CONTAINMENT YES_ NO IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND,BOTH IF APPUCABLE A. SYSTEM TYPE A U I SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER S. CONSTRUCTION A U 1 SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH Aq195 UNKNOWN A U 90 OTHER C. MATERIAL AND A U 1 BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A U 4 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 8 CONCRETE A U 7 STEEL W/COATING A U B 100% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION UNKNOWN A U 99 OTHER D. LEAK DETECTION ❑1 MEGWALAL 111E LMA ❑2 h vomIEMTLwREss I73M MElsmw [—]4MI� � O A� 5 =MIR99OTHER DE EC OR V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 RECONCILIATIONNUAL ORY ❑ 3 MONIITORING OZE ❑ 4 GAUGING AUTOMATIC TANK ❑5 GROUNDWATER ❑ 8 ANNUAL TESTING ❑ 7 MON TOR U INTERSTITIAL ❑ 8 SIR ❑ 9 WEEK LA MANUAL ❑t0 MOTESTINGHLY TANK ❑ 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) I.ESTIMATED DATE LAST USE ( Y2.ESTIMATED QUANTITY OF -\(�.\p1A/ ' 3.WAS TANK FILLED WITH YES NR SUBSTAGE REMAINING l�•L N GALLONS INERT MATERIAL? ❑ C❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT TANK OWNERS NAME DATE (PRINTED 6 SIGNATURE) LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COL_2L-! JURISDICTION FACILITYR OIoZ TANK �T STATE I.D.# s o 1510 11 Iq Ill 15D v PERMIT NUMBER PERMIT APPROVED BVIDATE PERMIT EXPIRATION DATE / THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPL'+ATION-FORM A,UNLESS A CURRENT FORMA HAS BEEN FILED. FORM C MUST BE COMPLETED FO RISTALLATIM TRS FORM SHOULD BE ACCOMPANIED BY A PLOT P RLE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THF 'ERGROUND STORAGE TANK REGULATIONS FORME (6-95) i—ter-