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rt� � � isounce5. STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD o UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B • rt Nf. COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. C9LiFd 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 ❑ 5 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED ©' DBA OR FACILITY NAME WHERE TANK IS INSTALLED: /// �/ •�I�� +�};t l�Lf /� ' I. TANK DESCRIPTION COMPLETE ALL ITEMS s- SPECIFY IF UNKNOWN A OWNER'S TANK I.D.# 75 1 B. MANUFACTURED BY: C. DATE INSTALLED(MO/DAYNEAR D. TANK CAPACITY IN GALLONS: II,TANK CONTENTS IF A-1 IS MARKED,COMPLETE ITEM C. w-v A. 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C ❑ 1a REGULAR UNLEADED 3 DIESEL ❑ 6 AVZATIONGAS ❑ 2 PETROLEUM ❑ 80 EMPTY � 1 PRODUCT F7 lb PREMIUM UNLEADED 4 GASAHOL ❑ 7 METHANOL ❑ Ic MIDGRADE UNLEADED ❑ 5 JET FUEL 8 M85 ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED ❑ 99 OTHER(DESCRIBE IN ITEM 0.BELOW) D. IF(A.T)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S.0: 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 2 SINGLE WALL ❑ 4 StNGLE WALL IN A VAULT ❑ 99 OTHER B. TANK ❑ 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS Y4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100/ METHANOL COMPATIBLEW/FRP (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER C.INTERIOR ❑ 1 RUBBER LINED F7 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 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 ❑ 95 UNKNOWN ❑ 99 OTHER E.SPILL AND OVERFILL,@tC, SPILL CONTAINMENT IN TALLED(YEAR) i OVERFILL ENTION EQUIPMENT INSTALLED(YEAR) DROP TUBE YES NO STRIKER PLATE YESX 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 Ac? PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION A 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 U 1 BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)?U9FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEELW/COATING A U B 100% METHANOL COMPATIBLEW/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION 1 MECHANICAL UNE LEAK 2 LINE TIGHTNESS 3 CONTINUOUS INTERSTmAL 4 ELECTRONIC LINE 5 AUTOMATIC PUMP ❑ DETECTDR ❑ TESTING MONITORING LEAK DETECTOR SHUTDOWN ❑ 99 OTHER V.TANK LEAK DETECTION ❑ ANNUAL 1 VISUAL CHECK El2 RECONCIL TIONQRY [7] 3 VMONITORING GAUGING IC TANK F--] 5 MON TORINGGROUND WATER ❑ G TESTINGTANK 7 MONITORING CONTINUOUSINTERSTITIAL E] B SIR ❑ 9 TANK LY MANUAL ❑ 10 MOSTINGY TANK D 95 UNKNOWN F-199 OTHER VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) 1.ESTIMATED DATE LAST USED(MO/DAYIYR) 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 G SIGNATURE LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY# TANK# r f STATE I.D:# m PERMIT NUMBER PERMIT APPROVED BYlDATE PERMIT EXPIRATION DATE THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLIC N- ORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. FD MUST BE COMPLETED FOR INSTALLATIONS. THIS FORM SHOULD BE ACCOMPANIED BY A PLOT PILEFTHIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE JWGROUND STORAGE TANK REGULATIONS FORM 6 (6-95)