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STATEOFCALIFORNIA - •°'' i. STATE WATER RESOURCES CONTROL BOARD d <o UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B ;n T . COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION F7 7 PE OSED ON TE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE 8 T DBA OR FACILITY NAME WHERE TANK IS INSTALLED: I. TANK DESCRIPTION COMPLETE ALL ITEMS— SPECIFY IF UNKNOWN A OWNER'S TANK I.D.# B. MANUFACTURED BY: C. DATE INSTALLED(MO/DAYNEAR) D. TANK CAPACITY IN GALLONS: II.TANK CONTENTS IFA-1 IS MARKED,COMPLETE ITEM C. A. �1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C. ❑ 1a REGUU UNLEADED �3 DIESEL ❑ 6 AVIATION GAS 2 PETROLEUM ❑ 80 EMPTY ,I��/1 PRODUCT ❑ 1b PREMIUM UNLEADED 4 GASAHOL ❑ 7 METHANOL ❑ jf�" ❑ 1c MIDGRADE UNLEADED ❑ 5 JETFUEL ❑ 8 M85 ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED ❑ 99 OTHER(DESCRIBE IN REM D.BELOW) 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 E A. TYPE OF ❑ I DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 5 INTERNAL BLADDER SYSTEM ❑ 95 UNKNOWN SYSTEM >K4 SINGLE WALL ❑ 4 SINGLE WALL IN A VAULT ❑ 99 OTHER B. TANK ❑ 1 BARE STEEL ❑ 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 Tank 10 GALVANIZED STEEL 95 UNKNOWN 99 OTHER ( TY I ❑ 9 BRONZE ❑ ❑ C.INTERIOR ❑ 1 RUBBER UNED ❑ 2 ALKYD LINING ❑ 3 EPDXY UN141G ❑ 4 PHENOLIC LINING LINING OR ❑ 5 GLASS LINING 6 UNLINED ❑ 94,i NS(N ' 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? NES_ NO—X D.EXTERIOR ❑ 1 POLYETHYLENE WRAP 2 COATIN9 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC CORROSION / 95 UNKNOWN 99 OTHER PROTECTION ❑ 5 CATHODIC PROTECTION 1`� ❑ ❑ 'BP181.ICONTAINMENT 11 STAL D(YEA OVERFILL PREVENTION OUIPMENT INSTALLED(NEAR) E.SPILL AND OVERF!4,BSC.':DROP TUBE YES_ NO STRIKER P YES_ NO DISPENSER CONTAINMENT VES_ NO IV.PIPING INFORMATION CIRCLE AIFABOVE GROUND„ 6F4A R ROUND,BOTH IF APPLICABLE A.:SYSTEM TYPE A 1 SUCTION ''A 2 PRESSURE A U 3 GRAVITY A U 4 FUMBLE PIPING A U 99 OTHER ' B. CONSTRUCTION A ly +IjLf A U 2 D LE + A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND y A�RESTEEL .A U ESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A U 4 FIBERGLASS PIPE CORROSION / 5 ALUMINUM CONCRETE A U 7 STEEL W/COATING A U 8 100% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GAL sEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION - ' 1 E LF,vc ❑2 UNE TIGMNESS ❑3 CONTIG VIA15 NIERSii]ML ❑4 EIECGiONIC UNE 5 AUTOMATIC POMP 99 GTHER CTOR TESTNG MOMTORNG LEA#DETECTOR ASH UTO TIN V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK _ 2 MANUAL INVENTORY ❑ 3 MONIITORING ❑ 4 GAUGING AUTOMATIC TANK ❑5 GROUND MONITOR 1 8 TESTINGTANK RECONCILIATION "yL��J11L� ❑ 7 CONTINUOUS MONITORING INTERSTITIAL 8 SIR ❑ 9 TANK GAUGING TESTING❑10 MONTHLY TANK ❑ 95 UNKNOWN 99 OTHER VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PUCE) 1.ESTIMATED D MO AY/YR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES ❑ NO DATE LAST USE - _ SUBSTANCE REMAINING GALLONS INERTMATERIAL? THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT DATE TANK OWNER'S NAME ' (PRINTED 4SIGNATURE) LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION It FACILITY# TANK# STATE I.D.# PERMIT NUMBER P PERMIT APPROVED BY/DATE 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 PLOILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE GROUND STORAGE TANK REGULATIONS FORM (6-95) - ,CJ,1 oAw4m