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ces STATE OF CALIFORNIA `i STATE WATER RESOURCES CONTROL BOARD "� b UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B =° ( COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ❑ I NEW PERMIT O 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION O 7 PERMANE CLOSED ON ONE ITEM ❑ 2 INTERIM PERMIT F—] 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE 8 TANK R VED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: - '—{- I. TANK DESCRIPTION COMPLETE ALL ITEMS— SPECIFY IF UNKNOWN A OWNER'S TANK I.D.N B. MANUFACTURED BY: p '7� C. DATE INSTALLED(MOHDAYNEAR) �` D. TANK CAPACITY IN GALLONS: / If.TANK CONTENTS IF A-1 IS MARKED,COMPLETE ITEM C. A I MOTOR VEHICLE FUEL ❑ 4 OIL 8.�./ C, REGULAR UNLEADED 3 DIESEL ❑ 6 AVIATION GAS ❑ 2 PETROLEUM ❑ 80 EMPTY IXI 1 PRODUCT PREMIUM UNLEADED 4 GASAHOL 7 METHANOL K 1c MIDGRADE UNLEADED 5 JETFUEL ❑ 8M85 ❑ 3 CHEMICALPRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE 2 LEADED El 99 OTHER(DESCRIBE IN ITEM D.BELOW) 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 BOX D AND E A. TYPE OF ❑ 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR UNER ❑ 5 INTERNAL BLADDER SYSTEM ❑ 95 UNKNOWN SYSTEM 2 SINGLE WALL ❑ 4 SINGLE WALL IN A VAULT O 99 OTHER B. TANK I BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD Wl FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP (Pftq Tank) ❑ 9 BRONZE O 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER C.INTERIOR ❑ I RUBBER UNED 7❑ 2 ALKYD LINING F-13 EPDXY LINING F-14 PHENOLIC LINING LINING OR ❑ 5 GLASS LINING IXI 8 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 795 UNKNOWN ❑ 99 OTHER E.SPILL AND OVERFILL,6T5. SPILL CONTAINME NSTA D R) fVQ OVERFlLL PREVENT( N EQUIPMENT INSTALLED(YEAR) DROP TUBE ) NO STRIKER PLATE YES_ NO DISPENSER CONTAINMENT ES_ NO IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION U 1 SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND A CU BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A U 4 FIBERGLASS PIPE CORROSION AY 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL W/COATING A U 6 100% 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 xun�cu uNE IRAIc 2�Sr 1NUHrTassmKrT�ss O 3 WS IxrensTmN ❑A E�cmaNp UW O 5 Aurw,unc Pulmo 5�"��,,_,f/_� [6Nf OETEOLOR SH9T90WN 99 OTHERt_L/YJYIi V.TANK LEAK DETECTION ❑ i VISUAL CHECK ❑ 2 MANUAL( IATION INVENTORY ❑ 3 MOMOTORING ❑ 4 GAUGINGC TANK ❑5 GROUND MONITOWATER ❑ 6 ANNUNGTANK ❑ 7 MONITORING NUOUSINTERSTITIAL ❑ 8 SIR ❑ 9 WEEKLY MANUAL ❑10 MONTHLY TANK g5 UNKNOWN ❑99 OTHER TANK GAUGING TESTING VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) I.ESTII A D DA E(AST 120/DAY/YR) 2.ESTIMATED OUANDTY OF 3.WAS TANK FILLED WITH YE 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 (PRNTED 4 51GNATJgET LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW STATE I.D:# COUNTY N JURISDICTION N FACILITY N TANK N 600-5 � r-T PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION UATEL�L�LJ THIS FORM MUST BE ACCOMPANIED BY A PERMIT APP rATION-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. FORM C MUST BE COMPLETED FOR INSTALLATIONS. THIS FORM FORM B (6-95) SHOULD BE ACCOMPANIED BY A PLOTRLE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE lRGROUND STORAGE TANK REGU6ATIqNS - 5--16- 97 � u�ya�