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STATE OF CALIFORNIA �+� STATE WATER RESOURCES CONTROL BOARD �yd� e o UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B i COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY C D ON SITE ONE ITEM ❑ 2 INTERIM PERMIT O 4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVE DBA OR FACILITY NAME WHERE TANK IS INSTALLED: I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A OWNER'S TANK I.D.M B. MANUFACTURED BY: C. DATE INSTALLED(MODAYIYEAR) D. TANK CAPACITY IN GALLONS: W II.TANK CONTENTS IF A-1 IS MARKED,COMPLETE ITEM C. A ❑ I MOTOR VEHICLE FUEL 4 OIL B. C. 1a REGULAR UNLEADED EJ3 DIESEL L] 6 AVIATIONGAS O2 PETROLEUM ❑ 80 EMPTY ❑ 1 PRODUCT E] 1b PREMIUM UNLEADED ❑ 4 GASAHOL ❑ 7 METHANOL ❑ is MIDGRADE UNLEADED ❑ 5 JETFUEL ❑ B M85 ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN 2 WASTE ❑ 2 LEADED ❑ 99 OTHER(OESCRIBE IN ITEM D.SELOY✓) D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A S.R: 05 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 O 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 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD N FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE O 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE WIFRP (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 85 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 10D% METHANOL? YES_ NO D.EXTERIOR ❑ 1 POLYETHYLENE WRAP F-1 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC CORROSION PROTECTION ❑ 5 CATHODIC PROTECTION X 91 NONE 95 UNKNOWN 99 OTHER E SPILL AND OVERFILL,BIC. SPILL CONTAINMENT INSTALLED R) OVERFILL PREVE N OUIPMENT INSTALLED(YEAR) DROP TUBE YES_ NO ST IKER 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 U 2 PRESSURE A )3 GRAVITY A U 4 FLEXIBLEPIPING A U 99 OTHER B. CONSTRUCTION A 1 SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND A4a;h 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 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 ❑ LIN 1 MiOMNOLL E LMR 2 E n9RT W ❑ c 3 IJWS WERSTma 4 ELEMMIC ME ❑5 A = 99 Pula DETEMNI ❑ IN TEEM MDMTmm ❑ IMM X7EMR EHmOYmOWN OTHER V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 MANUALINVENTORY LD 3 ❑ 4 AUTOMATIC TANK [:]5 TER F-1 6 TESNTAN RECONCILIATIONMONITORING GAUGING GROUND WATER TETIGK ❑ 7 MONITORING INTERSTITIAL ❑ 8 SIR ❑ 9 TANK=AL ❑10 MONT NG HLY TANK E] 95 UNKNOWN �89 OTHER VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) 1.ESTIMATED DATE LAST USED(MO/DAY/VR) 2.ESTIMATED QUANTITY OF 3.WAS STANK FILLED HATH SUBSTANCE REMAINING GALLONS INERTMATERIAL? YES O NO 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 R 510NATJF k LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW STATE I.D:# COUNTY R JURISDICTION R FACILITY R PERMIT NUMBER PERMIT APPROVED BYIDATE PERMIT PIRA 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) 1 V J/S X&&