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r /H!•e STATE OF CALIFORNIA e STATE WATER RESOURCES CONTROL BOARD 5 a UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B �� =� ( COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED 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: t— - I. TANK DESCRIPTION COMPLETE ALL ITEMS— SPECIFY IF UNKNOWN A OWNER'S TANK I.D.• .K B. MANUFACTURED BY: v C. DATE INSTALLED(MOHDAY/YEAR) /C D. TANK CAPACITY IN GALLONS: 00 IL TANK CONTENTS IF A-1 IS MARKED,COMPLETE ITEM C. A ❑ 1 MOTOR VEHICLE FUELOIL 8. C. 18 REGULAR UNLEADED ❑ 3 DIESEL ❑ 6 AVIATION GAS F7 2 PETROLEUM 80 EMPTY 1 PRODUCT ❑ 1b PREMIUM UNLEADED ❑ 4 GASAHOL ❑ ] METHANOL 8 M85 E:] 3 CHEMICALPRODUCT ❑ 95 UNKNOWN 2 WASTE ❑❑ 2 MLE DEDE UNLEADED 6 JOTHER(DESCRET FUEL ❑IBE IN ITEM D.BELOW) 0. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED B �/� ,G!` C.A.S.k 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 ❑ i 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 ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP (PrimaryTank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL 95 UNKNOWN ❑ 99 OTHER C.INTERIOR ❑ I RUBBER LINED ❑ 2 ALKYD LINING �❑ 33 EPDXY LINING E:] 4 PHENOLIC LINING LINING OR ❑ 5 GLASS LINING ❑ 6 UNLINED Sf95 UNKNOWN ❑ 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 10D% METHANOL? ES_ NO— D.EXTERIOR ❑ I POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC CORROSION PROTECTION ❑ 5 CATHODIC PROTECTION ❑ Bl NONE 95 UNKNOWN ❑ 99 OTHER E SPILL AND OVERFILL,610. SPILL CONTAINMENT INSTALLED(NEAR) OVERFILL PREVENTION EOUIPMENT INSTALLED(YEAR) DROP TUBE YES 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 U 2 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION A&i SINGLE WALL A U 2DOUBLE WALL A U 3 LINED TRENCH A 5 UNKNOWN A U 99 OTHER C. MATERIAL AND AO1 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 6 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 A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION1 NEOWarx ME IFAHc 2 ME 11GRTNE38 3 wrOwuaufi INreAS 4 EIEm C ME 5 AOIOMATw RIMP ❑ DE mw ❑ TESMG ❑ Mnwmnw9 IFAK OEIECTGII ❑ SHNDOWN 99 OTHER //.K V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 ❑ MANUAL INVENTORY ❑ 3 ❑ 4 C TANK ❑5 WATER ANNUALTMK ECO IUATONMONITORING GAUGING MONITORINGTESTING 7 CONTINUOUS INTERSTITIAL ❑ a SIR 97ELYMUAL ❑ 10 MONTHLY TANK 95 UNKNOWN 99 OTHER MONITORING NWEEKLY GAUGING NG VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PUCE) 1.ESTIMATED DATE T US (MOADAY]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 BELOW COUNTY M JURISDICTION N FACILITY# TANK a �7' STATE LDS 3 0 7 8 a 7 6/ 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 PLA'- 'ILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE V RGROUND STORAGE TANK REGULATIONS FORM B (6.95) �(