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• � nCC9 STATE OF CALIFORNIA •� ooi' STATE WATER RESOURCES CONTROL BOARD 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 ON SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT y-❑ 6 TEMPORARY TANK CLOSURE 8 TANK REMOVED c DBA OR FACILITY NAME WHERE TANK IS INSTALLED: F=, �..�.T�'�''�'�'�"'' f ✓ �� "��"{ I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A OWNER'S TANK L D.# B. MANUFACTURED BY: C. DATE INSTALLED(MO/DAY/YEAR) D. TANK CAPACITY IN GALLONS: o0 II.TANK CONTENTS IF A-1 IS MARKED,COMPLETE ITEM C. ❑ 1, REGULAR UNLEADED DIESEL ❑ 6 AVIATION GAS A. 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C' ❑ 1b PREMIUM UNLEADED GASAHOL ❑ 7 METHANOL E] 2 PETROLEUM ❑ 80 EMPTY PRODUCT ❑ iO MIDGRADE UNLEADED ❑ 5 JET FUEL ❑ 8 M85 ❑ 3 CHEMICALPRODUCT ❑ 95 UNKNOWN 2 WASTE ❑ 2 LEADED ❑ 99 OTHER(DESCRIBE IN ITEM O.BELOW) 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 ANDS A. TYPE OF F—] 1 DOUBLE WALL F-] 3 SINGLE WALL WITH EXTERIOR UNEP ❑ 5 INTERNAL BLADDER SYSTEM ❑ 95 UNKNOWN SYSTEM &2 SINGLE WALL F-14 SINGLE WALL IN A VAULT ❑ 99 OTHER JiL 1 BARE STEEL F--] 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B. TANK I` F--]MATERIAL ❑ 5 CONCRETE 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM E] B 100% METHANOL COMPATIBLE W/FRP (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER C.INTERIOR ❑ 1 RUBBER LINED7�❑ 2 ALKYD LINING ❑ 3 EPDXY LINING E] 4 PHENOLIC LINING LINING OR ❑ 5 GLASS LINING "-" 6 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER COATING IS LINING MATERIAL COMPATIBLE—WITH`10D% METHANOL? YES— NO- D.E7(TERIOR ❑ 1 POLYETHYLENE WRAP 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC CORROSIONg1 NONE ❑ 95 UNKNOWN ❑ 99 OTHER PROTECTION [:15 CATHODIC PROTECTIO SPILL CONT AINMENTINS' I -El,(YEAR) OVERFILL PREVENT( EDUIPMENTINS'fALLED(YEAR) E.SPILL AND OVERFILL,61C. DROPTUBE YES_ NO STRIKER PLATE YES_ NO_,N_ DISPENSER CONTAINMENT VE NO IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION A SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND A 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 STEEL W/COATING A U B 100% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER 1 MECNNaCAL LINE IF.AI( 2 UNE TR:WNE55 ❑3 CGNIINUWS INTEASTIML ❑4 EL IMMIC LINE 5 AUTOMATIC R1NP 99 OTHER � I D. LEAK DETECTION ❑ DETECTOR ❑ TEST MONITORING LEI.#DETIC AODWWN V.TANK LEAK DETECTION ❑ i VISUAL CHECK ❑ 2 RECONCILIATIONINVENTORY ❑ 3 MONIITORING ❑ 4 AUTOMA-nGAUGING C TANK ❑5 GROUND MONITORINGTER '❑ 66 ANNUAL TESTING ❑ 7 CONTINUOUS INTERSTITIAL ❑ 8 SIR ❑ 9 WANKLY MANUAL ❑10 MONTHLY TANK ❑ 95 UNKNOWN 79 OTHER MONITORING Y"-' VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) 1.ESTIMATED TE LAST USED(M9/DAV(YR) 2.ESTIMATED OUANTITV OF rj�' 3.WAS TANK FILLED WITH YES ❑ NO J'�L- 9 1 SUBSTANCE REMAINING _ •C^' GALLONS INERT MATERIAL 7 I` - 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 (PRINTE08 SIGNATURE) LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION If FACILITY � 'T= STATE LD:# PERMIT NUMBER PERMIT APPROVED BYIDATE PERMIT E%PIRATION 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)*LE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THEGROUND STORAGE TANK REGULATIONS, ` FORM B (6.95)