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STATE OF CAUFORNIA STATE WATER RESOURCES CONTROL BOARD ` ' c~o UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B "� = l COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM, MARK ONLY 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATIONO 7 PERMANENTLY CLOSE E ONE ITEM 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT E:36 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A OWNERS TANK I.D.• B. MANUFACTURED BY: XC.� C. DATE INSTALLED(MO'DAYNEAR) D. TANK CAPACITY IN GALLONS: /^ oo II.TANK CONTENTS IFA-1 IS MARKED.COMPLETE ITEM C. V A �1 MOTOR VEHICLE FUEL ❑ 4 OIL B. ppp-��I C. to REGUUR UNLEADED O 3 DIESEL ❑ 6 AVIATION GAS ❑ 2 PETROLEUM ❑ 80 EMPTY f�L 1 PRODUCT 1D PREMIUM UNLEADED o 4 GASAHOL ❑ 7 METHANOL �l le MOGRADE UMEADED 5 JET FUEL ❑ BMW ❑ 3 CHEMICAL PRODUCT ❑ BS UNKNOWN 2 WASTE ❑ 2 LEADED 99 OTHER(DESCRIBE W RM D.BELOW) D. IF(A1)IS NOT MARKED, ENTER NAME OF SUBSTAGE STORED C.A S.M III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.B,AND C,AND ALL THAT APPLIES IN BOX D AND A. TYPE OF 1 DOUBLE WALL O 3 SINGLE WALL WITH EXTERIOR UNER ❑ 5 INTERNAL BLADDER SYSTEM ❑ 95 UNKNOWN SYSTEM 2 SINGLE WALL ❑ 4 SINGLE WALL IN A VAULT ❑ 99 OTHER B. TANK ❑ 1 BARE STEEL O 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 (Primary Tmk) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER C.INTERIOR ❑ I RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING LINING OR ❑ 5 GLASS LINING 8 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 CE1 91 NONE ❑95 UNKCWN ❑ 99 OTHER E.SPILL AND OVERFILL,BM. SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSGLLEO(YEAR) DROP TUBE VES A NO STRIKER PLATE YES NO— DISPENSER CONTAINMENT VES NO- IV. _IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTIONU 2 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL A IIQ2 DOUBLE WALL A U 3 UNED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND A U i BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A©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 CATHO IC PROTECTION A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION 1 IEGIIALN UK HENT 2 U1E TKWRESS 3 LCNrrAlOus W1FPS11fMt 4:ECM IBE 5 AI=MII K SAW ❑ ❑ OEIE4T011 IEmxe LIp14tORNG IFAK OEIECIOR 9AIIODBII 99 OTHER V.TANK LEAK DETECTION 1 VISUAL CHECK ❑ 2 RMECO CIUATONUAL ORV ❑ 3 XNOIT)RING 4 GAUGING NG AUTOMATIC TANK ❑5 MON TORINGTER ❑8 ANNUAL TESTINGTANK 7 CONTINUOUS 1 .4 MONITORING INTERSTITIA ❑ 8 SIO ❑ 9 MEXGAUGING� ❑10 TMESTNTINGY TANK O 95 UNKNOWN E::] 99 OTHER VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) 1.ESTIMATED DATE LAST USED(MO/DAYNR) 2.ESTIMATED QUANTITY OF3.WAS TANK FILLED WITH YES Q C O SUBSTAGE 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 OWNERS NAME //�) DATE (PRIMED d SIGNATURE) _-� - / / LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR duMBERS BELOW COUNTY k JURISDICTION k FACILITY N TANK a STATE I.D:# m PERMIT NUMBER PERMIT APPROVED BYADATE 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 PV 9LE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE U"^FRGROUND STORAGE TANK p�Fy, LATNINS - FORM 8 (6 ) r� �� ILLI-'(/a}v'\p�fjlT