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.,, STATE OF CALIFORNIA a 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 CLOSED OH SITE ONE ITEM ❑ 2 INTERIM PERMIT O 4 AMENDED PERMIT ❑ 8 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 1.0.f B. MANUFACTURED BY: \ C. DATE INSTALLED(MOtDAY/YEAR) D. TANK CAPACITY IN GALLONS: II.TANK CONTENTS IF A-1 IS MARKED,COMPLETE ITEM C. A 1 MOTOR VEHICLE FUEL ❑ 4 OIL IL C. le REGUTAR UNLEADED 3 DIESEL ❑ 8 AVIATION GAS 2 PETROLEUM ED !b EMPTY IXI 1 PRODUCT Ib PREMIUM UNLEWED 4 GASAHOL ❑ 7 METHANOL TT--" 1C MDGWE UNLEADED ' JET FUEL O B M85 O 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE Q 2 LEADED 99 OTHER(OESCRBE N ITEM D.BROW) D. IF(AL1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S f III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.8.AND C.AND ALL THAT APPLIES IN BOX D AND E A. TYPE OF1 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 O 2 STAINLESS STEEL 3 FIBERGLASS O 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE O 8 POLYVINYL CHLORIDE9 7 ALUMINUM O 8 100% METHANOL COMPATIBLE W/FRP (PHm9ry Tank) ❑ 9 BRONZE O 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER C.INTERIOR ❑ I RUBBER LINED 0 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING LINING OR ❑ 5 GLASS LINING ITV 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 ❑ 91 NONE ❑85 UNKNOWN ❑ 99 OTHER E.SPILL AND OVERFILL,BLD. 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 AU 2 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 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) U 4 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U B 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 CPROTECTION A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTIONI M[a L tAIE IFAK 2 U E TMI9N96 3 cemAm93 NT915Tn91 4 NE0TR9IA0 DIE 9 m F9w ❑ RIECfgi TFSRI9 IIt11RdfI0 IEVf t1E1ECTOR ❑5 mff9NTOOWX ❑ 99 OTHER V.TANK LEAK DETECTION i VISUAL CHECK ❑ 2 MANUAL RECONCILIATIONINVENTORY ❑ 3 VADOZEMONITORING O 4 AUTOMATIC GAUGING TANK [—]5 GROMONITND WATER ORING ❑8 TANK TESTING 7 MONITORING INTERSTITIAL ❑ B SIR ❑ B WEEKLY MFNUAL ❑10 MONTHLY TANK ❑ 95 UNKNOWN ❑99 OTHER VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) 1.ESTIMATED DATE LAST USED(MO/DAY/YR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES Q 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 (PRINLED 6 SmNATUREI_� LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY* JURISDICTION N FACILITY k TANK STATE I.D.# m PERMIT NUMBER PERMIT APPROVED BYIDATE PERMIT EXPIRATION DATE THIS FORM MUST BE ACCOMPANIED BY A PERIBTAPPLICATION•FORMA,UNLESS A CURRENT FORMA MAS BEEN FILED. FORM C MUST BE COMPLETED FOR INSTALLATIONS. THIS FORM SHOULD BE ACCOMPANIED BYA PLOT PWM. RLE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS FORMS (&95)