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to • STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD 4 UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B i 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 REM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: 5v/ w, Gal I. TANK DESCRIPTION COMPLETE ALL ITEMS– SPECIFY IF UNKNOWN A OWNERS TANK I.D.# / B. MANUFACTURED BY: v C. DATE INSTALLED(MO/DAY/YEAR) f 9 D. TANK CAPACITY IN GALLONS: 8 II.TANK CONTENTS IFA-1 IS MARKED,COMPLETE ITEM C. ��l MOTOR A ❑ 2 PETROLEUM 80 FUEL O BO OILB. B �' 1 PRODUCT C ❑ 1e REGULAR UNLEADED ❑ 3 DIESEL ❑ 6 AVIATION GAS 10 PREMIUM UNLEADED ❑ 4 JET FUEL ❑ 7 METHANOL 1c MIDGRADE UNLEADED ❑ 5 JET FUEL ❑ 8 M85 ❑ 3 CHEMICALPRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED ❑ 99 OTHER(DESCRIBE IN ITEM D.BELOM D. IF(A.1)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 ❑ 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 5 INTERNAL BLADDER SYSTEM L] 95 UNKNOWN SYSTEM [!� 2 SINGLE WALL ❑ 4 SINGLE WALL IN A VAULT ❑ 99 OTHER B. TANK f�il 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 1001/6 METHANOL COMPATIBLE W/FRP (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL 95 UNKNOWN 99 OTHER C.INTERIOR ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING LINING OR ❑ 5 GLASS LINING ffi 6 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 10D% METHANOL? YES_ NO— D.EXTERIOR ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC CORROSION PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE95 UNKNOWN ❑ 99 OTHER E.SPILL AND OVERFILL,BfC. SPILL CONTAINMENT INSTALLED(YEAR) OVERRLL 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 A PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION A 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)A U 4 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 S//T�EE.E..L��W/COATING A U 8 100% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION Al2:05 UNKNOWN A U 99 OTHER D. LEAK DETECTION 1 MECHMIGL LINE LEAK 2 UNE NESS3 OCMINUOUS INTEPSIMAL 4 ELEMMIO LINE 5 AUfOW11C PUMP ❑ DETECTOR ❑ MIO TESTING MOMTMNG LEAK MMMOR SHOm ❑ 99 OTHER V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK 2 MANUAL RECONCILIATION MOND[D3 VAOZEMON ORING ❑ 4 GAUGING AUTOMATIC TANK ❑5 GROUND MONITORING TER TANK 9 TESTING ❑ 7 MONITORCONTINUOUS INTERSTITIAL ❑ 8 SIR ❑ 9 WEEKLY MANUAL ❑10 MONTHLY TANK ❑ 95 UNKNOWN ❑ 99 OTHER G TESTING 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 NO SUBSTANCE REMAINING GALLONS INERTMATERIAL7 ❑ ❑ 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 (PRIMED a SIGNATURE) LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY# TANK# STATE I.D.# z s zvrzh1 PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE 2/2314 THIS FORM MUST BE ACCOMPANIED BY PERMIT AP ATION-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. FORM C MUST BE COMPLETED FOR INSTALLATIONS. THIS FORM SHOULD BE ACCOMPANIED BY A PL FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS FORM B (6.95) 49