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0 STATE OF CALIFORNIA 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 ONSITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED B. TANK ❑ 7 BARE STEEL ❑ UNLEADED G DBA OR FACILITY NAME WHERE TANK IS INSTALLED: K6; n Z --Gd / s4!/� ❑ 99 OTHER (DESCRIBE IN REM D. BELOW) I. TANK DESCRIPTION COMPLETE ALL ITEMS— SPECIFY IF UNKNOWN A OWNER'S TANK I. D. p -MANUFACTURED K/ C. DATE INSTALLED(MO/DAYNEAR) �� CI D. TANK CAPACITY IN GALLONS: 11. TANK CONTENTS IFA -1 IS MARKED, COMPLETE ITEM C. A MOTOR VEHICLE FUEL ❑ 4 OIL B. C. ❑ 1e REGULAR UNLEADED ❑ 3 DIESEL ❑ 6 AVIATIONGAS ❑ 2 PETROLEUM ❑ BO EMPTY PRODUCT uQ`\lfcb PREMIUM UNLEADED ❑ 4 GASAHOL ❑ 7 METHANOL B. TANK ❑ 7 BARE STEEL ❑ UNLEADED ❑ 5 JET FUEL ❑ BM85 ❑ 3 CHEMICALPRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE LEADEMIDGRAD ❑ 2 LEADED ❑ 99 OTHER (DESCRIBE IN REM D. BELOW) D. IF (XI) IS NOT MARKED, ENTER NAME OFSUBSTANCE 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 2�7 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 5 INTERNAL BLADDER SYSTEM ❑ 95 UNKNOWN SYSTEM ❑ 22 SINGLE WALL ❑ 4 SINGLE WALL IN A VAULT ❑ 99 OTHER B. TANK ❑ 7 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS 4 STEEL CLAD Wl FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM 8 100% METHANOL COMPATIBLE W/FRP (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL 95 UNKNOWN ❑ 99 OTHER C. INTERIOR ❑ 1 RUBBER LINED ❑ 2 ALKYD LININGAAA.❑..,,��,, 3 EPDXY LINING ❑ 4 PHENOLIC LINING LINING OR F-15 GLASS LINING ❑ 6 UNLINED �95 UNKNOWN ❑ 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES— NO— D, EXTERISIONOR ❑ 1 POLYETHYLENE WRAP E]2 COATING ❑ 3 VINYL WRAP FIBERGLASS REINFORCED PLASTIC CORRO PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE ❑95 UNKNOWN 99 OTHER E SPILL AND OVERFILL, BLC. SPILL CONTAINMENT INSTALLED (YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED (YEAR) DROP TUBE VES_ 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 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL A DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND CORROSION PROTECTION A U A U A U 1 BARE STEEL 5 ALUMINUM 9 GALVANIZED STEEL A U A U A U 2 STAINLESS STEEL A U 6 CONCRETE A U 10 CATHODIC PROTECTION 3 POLYVINYL CHLORIDE (PVC)A U 4 FIBERGLASS PIPE 7 STEEL W/COATING A U B 100% METHA OL COMPATIBLE W/FRP A U 95 UNKNOWN �99 OTHER_ D. LEAK DETECTION 1 Aff01VNICAI uxE IFAK ❑ CETECfOP ❑ 2 TE TIGx9,9ss 3 comTUWS 6NTERSTIIIAL 4 ELEMOM0 UNE 5 Aff0WTK PUMP ❑ TESTING NiORING ❑ 1FAK DETECTOR ❑ SHU m 99 OTHER V. TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 MANUAL ECONCILATIONORV ❑ 3 VAOZEMONIITORING ❑ 4 AUTOMATGAUGING MONITORING TANK ❑ 5 GROUND MONTORINGTER ❑ 6 ANNUALTESTING CONMON INUOU INTERSTITIAL ❑ 8 SIR E]9 TANK WEEKLY MANUAL ❑ 10 MONTHLY TANK ❑ 95 UNKNOWN ❑ 99 OTHER VI. TANK CLOSURE INFORMATION (PERMANENT CLOSURE IN-PLACE) 1. ESTIMATED DATE LAST USED (MO/DAYNR) 2. ESTIMATED QUANTITY OF 3. WAS TANK FILLED WITH SUBSTANCE REMAINING GALLONS INERT MATERIAL? YES ❑ NO ❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT ATE (PRINTED a SIGNATURE) TANK OWNER'S NAME D LOCAL AGENCY USE ONLY THE STATE I.D. NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY # JURISDICTION # FACILITY # TANK # D STATE I.D.# m 1- 1 PERMIT NUMBER PERMIT APPROVED BV/DATE PERMIT EXPIRATION DATE 1 / ?TOA THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLION • FORM A, UNLESS ACURRENT FORM A HAS BEEN FILED. FORM C MUST BE COMPLETED FOR INSTALLATIONS. THIS FORM SHOULD BE ACCOMPANIED BY A PLOT P RLE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THIERGROUND STORAGE TANK REGULATIONS FORM B (6 95)