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• STATE OF CALIFORNIA • .°"�.��'' °t s STATE WATER RESOURCES CONTROL BOARD W d 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 CLOS ONSITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE Ejal-li TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: "-'` C/1P'c 1 I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A OWNER'S TANK I.D.a B. MANUFACTURED BY: C. DATE INSTALLED(MOMAY/YEAR) D. TANK CAPACITY IN GALLONS: II.TANK CONTENTS IF A-1 IS MARKED,COMPLETE ITEM C. A. � MOTOR VEHICLE FUEL ❑ 4 OIL B. 0, ie REGUL4R UNLEPDED 3 DIESEL ❑ 6 AVIATION GAS ❑ 2 PETROLEUM ❑ 80 EMPTY ✓�1 PRODUCT ❑ 1b PREMIUM UNLEADED ❑ 4 GASAHOL ❑ 7 METHANOL ❑ 10 MIDGRADE UNLEADED ❑ 5 JET FUEL ❑ 8 M85 ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED ❑ 99 OTHER(DESCRIBE IN IT EM D.BE]OM 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 SYSTEMV❑' 2 SINGLE WALL ❑ 4 SINGLE WALL IN A VAULT ❑ 99 OTHER B. TANK E 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLAs nC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 IDO% METHANOL COMPATIBLE W/FRP (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER C.INTERIOR ❑ I RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING LINING OR ❑ 5 GLASS UNING B2-�61JNUNED ❑ 95 UNKNOWN ❑ 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES— NO— D.EXTERIOR ❑ 1 POLYETHYLENE WRAP d2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC CORROSION 91 NONE ❑95 UNKNOWN ❑ 99 OTHER PROTECTION ❑ 5 CATHODIC PROTECTION [:1 SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION E UIPMENT INSTALLED(YEAR) DROP TUBE YES_ NO DISPENSER CONTAINMENT YES_ NO E.SPILL AND OVERFILL,ate. NO S STRIKER PLATE VES IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U I SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION 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 A5 ALUMINUM A U 6 CONCRETE A U 7 STEEL W/COATING A U 8 100% METHANOL COMPATIBLE W/FRP PROTECTION AU 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER 1 MECNNa ME"FAN 2 NNE MOHMESS 3 LONMNUWS INTERSTIIW. ❑4 EU:0111ONIC UNE ❑5 AIROrMTIC FUMP ❑ 99 OTHER D. LEAK DETECTION ❑ �� ❑ TEsnxG ❑ NOWMIM "EAN MRECTOR sNur9ovm V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK E1 2 FIECONCIUATIONINVENTORY ❑ 3 MONIITORING OZE ❑ 4 GAUGNGIC TANK ❑ 5 GROUND MONTORINGTER ❑ 6 TESTINGTANK ❑ 7 MONITORING INTERSTITIAL ❑ 8 SIR ❑ 9 WANK LY MANUAL ❑10 TESTINGMONTHLY TANK �95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) 1.ESTIMATED DATE LAST USED(MO/DAV/YR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES ❑ NO ❑ SUBSTANCE REMAINING GALLONS INERT MATERIAL? THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST F MY KNOWLEDGE,IS TRUE AND CORRECT TANK OWNER'S NAME ..' DATE (PRINTED a SIGNATURcyr..P _ �, U LOCAL AGENCY USE ONLY 41E STATE I.D.NUMBER IS COMPOSED OF TH R NUMBERS BELOW ��-- COUNTY# JURISDICTION# FACILITY# K r/_ — STATE 04m Z zj / (o ,/raj PERMIT NUMBER PERMIT APPROVED SYIDATE PERMIT EXPIRATION DATE THIS FORM MUST BE ACCOMPANIED BY A PERMIT APP TION•FORM A,UNLESS A CURRENT FORM A HAS BEEN FILEM C MUST BE COMPLETED FOR INSTALLATIONS. THIS FORM SHOULD BE ACCOMPANIED BN PLO • FlLE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING IVIDERGROUND STORAGE TANK REGULATIONS . FORM B (6-95)