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STATE OFCAUFORNIA ��.w�« 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 ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSE ON SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ B TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A. OWNER'S TANK 1.D.J B. MANUFACTURED BY: v C. DATE INSTALLED(MO/DAYNEAR) v D. TANK CAPACITY IN GALLONS: 3 �� ILTANK CONTENTS IFA-11S MARKED,COMPLETE ITEM C. p ❑ 1 MOTOR VEHICLE FUEL Il��J 4 OIL B. T� C. ❑ 1a REGULAR UNLEADED ❑ 3 DIESEL ❑ 6 AVIATION GAS ❑ 2 PETROLEUM u SO EMPTY 8 M85 L._J 1 PRODUCT ❑ 10 PREMIUM UNLEADED ❑ 4 GASAHOL ❑ 7 METHANOL ❑ ❑ O P MI DDE UNLEADED ❑ 98 JET LER(DESCO M REM D.BELOW) 3 CHEMICAL PRODUCT 95 UNKNOWN 2 WASTE D. IF(A.1)IS NOT MARKED, ENTER NAME OFSUBSTANCE STORED oArisz CJ RF C.A-S.J: 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 11 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 W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 8 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP (Primary Tank) ❑ 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 UNING ❑ 6 UNUNED a95 UNKNOWN ❑ 99 OTHER COATING IS UNING 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 fNL95 UNKNOWN ❑ 99 OTHER E.SPILL AND OVERFILL,81C. SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT 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 FLEXIBLEPIPING A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A®95 UNKNOWN A U 99 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 6 CONCRETE A U 7 STEEL W/COATING A U 8 100% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION Aff 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION ❑1 MEGMMW LINE LEAK 2 IME TMNTNE58 3 OYrtRMOU3 1M Trk 4 MM MC UNE 5 AVOW=PIMP DErEam ❑ numm ❑ MOMTO UAK OEIEOTOR E] MNToom1 ❑ 99 OTHER le V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 MANUAL INVENTORY ❑ 3 VADOZE MONITORING ❑ 4 GAUGINGIC TANK 5 GROUND MONTORINGTER ❑ 6 ANNUALTESTING ❑ 7 CONTINUOUSINTERSTITIAL ❑ B SIR ❑ING 9 WEEKLY E K LY MANUAL ❑ 10 TESTINGY TANK 95 UNKNOWN E:]99 OTHER VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PUCE) 1.ESTIMATED DATE LAST USED(MO/DAY/YR) 2.ESTIMATED OUANTITY OF 3.WAS TANK FILLED WITH SUBSTANCE REMAINING GALLONS INERT MATERIAL 7 YES ❑ NO 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 8 SIGNATURE) LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# �--_-F�A�C-IL�ITY# -� TANK# U�QYS STATE I.D:# FM l�JL� IXJPERMIT NUMBER ERMIT APPROVED SYIDATE PERMIT EXPIRATION DATE �jz THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORMA HAS BEEN FILED. FORM C MUST BE COMPLETED FOR INSTA-LLATIDNS THIS FORM SHOULD BE ACCOMPANIED BY A PLOT PLAN. FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE I IGROUND STORAGE TANK REGULATIONS FORM 8 (6-95) 1 NW