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0 0 STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. D �.- MARK ONLY Q 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSE E ONE ITEM❑ RE ❑ 8 TANK REMOVED 2 INTERIM PERMIT O 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE DBAOR FACILITY NAME WHERE TANK IS INSTALLED: S4 E�<" CACa r!1 *,Cll /ix �.R I,A t,,l �� 1Atkr� La I TANK nPArRIPTION CnMPI FTP Al L ITEMS- SPECIFY IF UNKNOWN A OWNER'S TANK I. D. # /01/-S B. MANUFACTURED BY: ! FA v E LCTt /N C. DATE INSTALLED (MOIDAWYEAR) 0 G - / S - 7r D. TANK CAPACITY IN GALLONS: .2 Uj UO G! I ❑ 2 WASTE It TAKIV rnMTPMTC ,e e_„c ueoMen enr..lm FTF ITRMC A,❑ 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C. 1a REGULAR UNLEADED ❑ 3 DIESEL ❑ 6 AVIATION GAS ❑ 1b PREMIUM UNLEADED ❑ 4 GASAHOL ❑ 7 METHANOL ❑ 2 PETROLEUM ❑ 80 EMPTY 1 PRODUCT ® 10 MIOGRADE UNLEADED ❑ 5 JET FUEL ❑ 8 M85 ❑ 3 CHEMICALPRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE 2 LEADED ❑ 99 OTHER (DESCRIBE IN REM D. BELOM 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 IV PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND. BOTH IF APPLICABLE A. SYSTEM TYPE 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 5 INTERNAL BLADDER SYSTEM ❑ 95 UNKNOWN A. TYPE OF SYSTEM ❑ 2 SINGLE WALL ❑ 4 SINGLE WALL IN A VAULT ❑ 99 OTHER A U� 2 DOUBLE WALL A U ❑ 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/ FIBERGLASS REINFORCED PLASTIC B. TANK MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ® B 100% METHANOL COMPATIBLE WIFRP (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER 2 NNE TIG111165a ®3 LIXInNUWS a1rERETmAL ❑ 4 BECiM MC UNE CJI 5 AUmM m' PUMP O 99 MER TESRNN MCMTORING [EAI( CEIE4TOR ICJ ERUTDDWN ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING C. INTERIOR LINING OR ❑ 5 GLASS LINING [2 6 UNLINED ❑ 95 UNKNOWN E]99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES -Z NO— D. EXTERIOR ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC CORROSION ❑ PROTECTION ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER PROTECTION 5 CATHODIC SPILL CONTAINMENT INSTALLED(YEAR) x OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) YES NO E. SPILL AND OVERFILL, BIC. DROP TUBE YES NO_ STRIKER PLATE YES V NO_ DISPENSER CONTAINMENT IV PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND. BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION A .,,, ,) 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 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND CORROSION A U A U 1 BARE STEEL 5 ALUMINUM A U 2 STAINLESS STEEL A U A U 6 CONCRETE A U 3 POLYVINYL CHLORIDE (PVC)A U 4 FIBERGLASS PIPE 7 STEEL W/COATING A08 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 1 YECHNACAL UNE IHJ( ❑ C ctm 2 NNE TIG111165a ®3 LIXInNUWS a1rERETmAL ❑ 4 BECiM MC UNE CJI 5 AUmM m' PUMP O 99 MER TESRNN MCMTORING [EAI( CEIE4TOR ICJ ERUTDDWN V. TANK LEAK DETECTION F-1 1 VISUAL CHECK ❑ 2 RECONCILIATIONORY ❑ 3 MONITORING ZE ©4 AUTOMATGAUG NGIC TANK ❑ 5 MONITORINGGROUND TESTING F-16 TTEESTINGNUAL TANK 7 MONITORINGINTERSTITIAL ❑ 8 SIR ❑ 9 TANKLY MAIrINUAL ❑ 10 MONTHLY TANK ❑ 95 UNKNOWN ❑ 99 OTHER VI. TANK CLOSURE INFORMATION (PERMANENT CLOSURE IN-PLACE) 1. ESTIMATED DATE LAST USED(MOIDAWYR) 2. ESTIMATED QUANTITY OF 3. WAS TANK FILLED WITH YES ❑ NO❑ SUBSTANCE REMAINING GALLONS INERT MATERIAL? TWIC rnann UAC r7rFN CnA,iPI FTFn UNDER PENALTY OF PERJURY. AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT TANK OWNER'S NAME DATE (PRINTED 6 SIGNATUPEI US! LOCAL AGENCY USE ONLY THE STATE I.D. NUMBER IS COMPOSED OF THE roux NUMUhKb tlCLUW • COUNTY # JURISDICTION # FACILITY # '% TANK # "02. STATE LD:# m L PERMIT NUMBER PERMIT APPROVED BYIDATE PERMIT EXPIRATION DATE THIS FORM MUST BE ACCOMPANIED BY A PERMIT APP N -FORM A, UNLESS A CURRENT FORMA HAS BEEN FILED. F C MUST BE COMPLETED FOR INSTALLAIIUNS. I NI5 runm SHOULD BE ACCOMPANIED BY A PLOT PWILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THIWRGROUND STORAGE TANK REGULATIONS FORM B (6-95)