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STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD ; a UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B u 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 ❑ B TANK REMOVED I DBA OR FACILITY NAME WHERE TANK IS INSTALLED: I, TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A OWNER'S TANK 1.D.III z_ B. MANUFACTURED BY: r rJ L U C. DATE INSTALLED(MOJDAYNEAR) D. TANK CAPACITY IN GALLONS: II.TANK CONTENTS IF A•1 IS MARKED,COMPLETE ITEM C. A 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C LJ 1a REGULAR UNLEADED ❑ 3 DIESEL ❑ 6 AVIATIONGAS ?f'2 PETROLEUM ❑ 80 EMPTY 1 PRODUCT ��"'c b PREMIUM UNLEADED ❑ 4 GASAHOL ❑ 7 METHANOL jMIDGRADE UNLEADED ❑ 5 JET FUEL ❑ 8 M85 ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN LJ 2 WASTE ❑ 2 LEADED ❑ 99 OTHER(DESCRIBE IN ITEM D.BELOW) D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S.#: 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 ❑ 95 UNKNOWN SYSTEM I—I 2 SINGLE WALL ❑ 4 SINGLE WALL IN A VAULT ❑ 99 OTHER B. TANK ❑ 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS 4 STEEL CLAD WI FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑"WWL 8 100% METHANOL COMPATIBLEWIFRP (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 LINING ❑ 6 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 1001/6 METHANOL? YES-)( NO D,EXTERIOR ❑ T POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP cz 4 FIBERGLASS REINFORCED PLASTIC CORROSION PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE ❑ 95 UNKNOWN ❑ 49 OTHER E.SPILL AND OVERFILL,etc. SPILL CONTAINMENT IbISTALUED(YEAR) OVERFI EVENTION 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 N PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER S. CONSTRUCTION A U 1 SINGLE WALL AV DOUBLE WALL A U 3 LINED TRENCH A U 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 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL WICOATING 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 MECHANICAL LINE LEAK ED 2 LINE TIGHTNeSS CONTINUOUS INTERSTMAL ❑4 ELECTRONIC LINE F'�I/AUTOMATIC PUMP ❑ 99 OTHER DETECTOR LJ TESTING MONITORING LEAK DETECTOR 1_.-^ SHUTDOWN V.TANK LEAK DETECTION 1 2 MANUAL INVENTORY ❑ 3 TO �4 GIC TANK ❑ MONfTORINGTESTING 5 TER E:] 6 TANK VISUAL CHECK 1:1MONI RECONCILIATION MONITORING GAUGING 7 MON INUOUS INTERSTITIAL E:] 8 SIR ❑ORING 9 TANKLY MANUAL ❑ 10 MOSTINLY TANK Ll 95 UNKNOWN Ll 99 OTHER VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) 1.ESTIMATED DATE LAST USED(MO/DAYNS) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES ❑ NO ❑ SUBSTANCE REMAINING GALLONS INERT MATERIAL 7 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 6 SIGNATURE) LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY# TANK# •"' � STATE I.D # m ❑� 7 Z /�/Y' PERMIT NUMBER PERMIT APPROVED BYIDATE PERMIT EXPIRATION DATE r _ 3 THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLIC ON-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. C MUST BE COMPLETED FOR INSTALLATIONS. THIS FORM SHOULD BE ACCOMPANIED BY A PLOT PRICE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THEORGROUND STORAGE TANK REGULATIONS FORM B (6-95)