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�r STATE OF CALF ORNIA : STATE WATER RESOURCES CONTROL BOARD 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 CLASON SITE ONE REM ❑ 2 INTERIM PERMIT ❑ a AMENDED PERMIT 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: a, I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A OWNER'S TANK 1.0.# I B. MANUFACTURED BY: C. DATE INSTALLED(MOIDAYNEAR) 192P 1 O. TANK CAPACITY IN GALLONS: II.TANK CONTENTS IFA-1 IS MARKED.COMPLETE TEM O A. X 1 MOTOR VEHICLE FUEL ❑ 4 OIL S. C, 7 la REGULAR UNLEADEDn`� 3 DIESEL ❑ 6 AVIATION GAS ❑ 2 PETROLEUM O 80 EMPTY ®' 1 PRODUCT /0 PREMAIM UNLEADED U a GASAHOL ❑ 7 METHANOL ❑ Ic MIOGRADE UNLEADED 5 JETFUEL ❑ B M85 ❑ 3 CHEMICALPRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED g 99 OTHER(DOCSSEN ITEMO.BELOW) D. IF(A1)IS NOT MARKED. ENTER NAME OF SUBSTANCE STORED C.A S#: III. TANK CONSTRUCTION MARK ONE TEEM ONLY IN BOXES A S.AND C.AND ALL THAT APPLIES IN BOX D AND S 2 A. TYPE OF 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 5 INTERNAL BUDDER SYSTEM ❑ 95 UNKNOWN SYSTEM ❑ 2 SINGLE WALL ❑ d SINGLE WALL IN A VAULT ❑ 99 OTHER B. TANK ❑ I BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS d STEEL CUD W1 FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE WIFRP (PHmary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER C.INTERIOR ❑ 1 RUBBER UNED ❑ 2 ALKYO LINING ❑ 3 EPDXY LINING ❑ d PHENOLIC LINING LINING OR ❑ 5 GLASS LINING ® 8 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO— D. O_D COO RIIOR F7 POLYETHYLENE WRAP ❑ 2 COATNG ❑ 3 VINYL WRAP A FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER E SPILL AND OVERFILL,etc. SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL 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 O I SUCTION A U 2 PRESSURE A U 3 GRAVITY A U A FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL A D Z DOUBLE WALL A U 3 UNED 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)AO s FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U a CONCRETE A U 7 ^TEFL W/COATING A U 3 100% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODI OTECTION A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION ❑1 4E4HWLAL MRE 11:A'L ❑2 IaE nGInKFss 3 ctNIPLaA NfFA6IIILLL ❑.OJLGLRCxC UtE ❑5 AUmw1IG vwn ❑ 99 rn»nI OmECfOR TFSIa10 YGNi(/Ipfi LEAH OEI=R MAITDOwx V.TANK LEAK DETECTION ❑ I VISUAL CHECK ❑ 2 ❑ MANUAL INVENTORY ❑ 3 ❑ A IC TANK GROUND WATER 6ANNUALTANK 7N INTERSTITIAL C:] ? MONITORING AUTOMATIC RMG = TESTING 8 SIR 9WELYMAE ❑10 MONTHLY TANK ❑ 95 UNKNOWN 99 OTHER MOTOR NG TANK NGHL VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PUCE) I.ESTIMATED DATE UST USED(MO/DAWYR) I 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH yES ❑ NO ❑ SUBSTANCE REMAINING GALLONS I INERT MATERIAL 7 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 (PRINTED 6 SIGNATURM LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW /y COUNTY# JURISDICTION# FACILITY# �7 I TANK# QU STATE LD: ES � I Y '7010I PERMIT NUMBER J C� PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLY jft- A,UNLESS A CURRENT FORM A HAS BEEN FILED. FO UST BE COMPLETED FOR INSTALLATIONS.THIS FORM SHOULD BE ACCOMPANIED BY A PLOT P .E THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THF. ROUND STORAGE TANK REGULATIONS FORM (6-95) \... q/ll / mR(XY