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• STATE OF CALIFORNIA • •"'"..;'o STATE WATER RESOURCES CONTROL BOARD �6 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 CLOSE SI ONE ITEM 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A OWNER'S TANK I.D.x N/A B. MANUFACTURED BY: Uk C. DATE INSTALLED(MO/DAYNEAR) Uk D. TANK CAPACITY IN GALLONS: 400 IL TANK CONTENTS IF A-1 IS MARKED,COMPLETE ITEM C. A. P 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C ie REGULAR UNLEADED ❑ 3 DIESEL ❑ 6 AVIATIONGAS ❑ 2 PETROLEUM ❑ 80 EMPTY i PRODUCT ❑ 1b PREMIUM UNLEADED ❑ 4 GASAHOL ❑ 7 METHANOL ED 1c MIDGRADE UNLEADED ❑ 5 JETFUEL ❑ 8 M85 E] 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE © 2 LEADED ❑ 99 OTHER(DESCRIBE IN REM D.BELO'M D. IF(At)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A S.x: 111. 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 ❑ 95 UNKNOWN SYSTEM ® 2 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 WIFRP (PH6Mry 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 En 6 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 10096 METHANOL? YES_ NO— D.EXTERIOR ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC CORROSION PROTECTION ❑ 5 CATHODIC PROTECTION ® 81 NONE ❑ 95 UNKNOWN ❑ 99 OTHER E.SPILL AND OVERFILL,Bic. 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 AQI 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION AO 1 SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND AQ 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 STEEL W/COATING A U 8 100% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION 1 MECWMCAL UNE UAN 2 LIME nONT1a55 3 COmNNWS Mn:Rm11AL 4 EIECI6GNIC UNE 5 AVfOMATL WAP ❑ GETECf011 ❑ n=.mNa ❑ MOMTORING ❑ LTN(pElEMR ❑ SMOWTIC ❑ 99 OTHER None V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 RECONCILIATIONNUAL INVENTORY ❑ 3 MONIITORING OZE E] 4 AUTOMATGAUGING MONITORING TANK E:] 5 GROUND MONTORINGTER ❑6 TESTING ❑ 7 MONITORING CONTINUOUSINTERSTITIAL ❑ 8 SIR ❑ 9 WEEKLY GAUGING ❑ 10 MONTHLY TANK ® 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) 1.ESTIMAftDATE LAST USED(MO/DAV/YR) 2 SUTBlMA STQUANTITY ANCE REMAINING 2'00 GALLONS 3 WASTANK FILLED NERT MATERIALI7H YES [:jNO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT TANK OWNER'S NAME ing, Inc . by H. Thorpe/Contractor DATE4/14/99 (PRINTED d SIGNATURE) LOCAL AGENCY USE 0 Y THE STATE I.D.N48ER IS COMPOSED OF THE FOUR NUMBERS BELOW STATE I.D:# COUNTY N JURISDICTION N FACILITY N�14-KTANK N 00 m PERMIT NUMBER 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 SLED. FORM C MUST BE COMPLETED FOR INSTALLATIONS. THIS FORM SHOULD BE ACCOMPANIED BY A PLOT POR LE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING NEW REBOUND STORAGE TANK REGULATIONS FORM B (685)