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• STATE OF CALIFORNIA s STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION -FORM B , ( COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ❑ i NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ON SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE �8 TANK REMOVED D DBA OR FACILITY NAME WHERE TANK IS INSTALLED: S , O I. TANK DESCRIPTION COMPLETE ALL ITEMS— SPECIFY IF UNKNOWN A OWNER'S TANK I.D.# —s— I B. MANUFACTURED BY: C. DATE INSTALLED(MO/DAYNEAR) WYW� 1 D. TANK CAPACITY IN GALLONS: ILTANK CONTENTS IFA-11S MARKED,COMPLETE ITEM C. A ❑ 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C, ❑ to REGULAR UNIEPDED 3 DIESEL ❑ 6 AVIATION GAS 2 PETROLEUM ❑ 80 EMPTY 1 PRODUCT ❑ 1b PREMIUM UNLEADED ❑ 4 GASAHOL ❑ 7 METHANOL ❑ is MIDGRADE UNLEADED ❑ 5 JET FUEL ❑ 8 M85 ❑ 3 CHEMICALPRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED ❑ 99 OTHER(DESCRIBE IN ITEM D.BELOW) D. IF(Ai)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S.a: 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 ❑ 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 5 INTERNAL BLADDER SYSTEM ❑ 95 UNKNOWN SYSTEM IN<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 W/FRP (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER C.INTERIOR ❑ 1 RUBBER UNED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING LINING OR ❑ 5 GLASS UNING )�Yi 6 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER COATING IS LINING MATERIAL COMPATIBLE �WITH 100% METHANOL? YES_ NOA' D.EXTERIOR ❑ 1 POLYETHYLENE WRAP2 COATING ❑ 3 VINYL WRAP E:] 4 FIBERGLASS REINFORCED PLASTIC CORROSION 91 NONE 95 UNKNOWN 99 OTHER PROTECTION ED CATHODIC PROTECTION ❑ ❑ SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) E.SPILL AND OVERFILL,BSC. 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& 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION Ajo 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 UU 3 POLYVINYL CHLORIDE(PVC)A U 4 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 6 CONCRETE A6)7)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 MECKWIWL UNE UE 2 UNE TrSNINESS 3=NUWS INTERSTDIAL 4 EMM NIC UNE ❑5 A OWU C PUMP 99 OTHER ce1ECraR ❑ MnNG ❑ MGMrMM ❑ tM DETECMR sKumowx V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 RECO CILIATIONORY ❑ 3 MONITORING ❑ TANK ANUAL VADOZE 4 AUTOMATGAUGING TANK ❑ 5 GROUND MONITORING ❑ 6 ANNUAL TESTING ❑ 7 MON TORNG INTERSTITIAL ❑ 8 SIR 9 WEEK LY MANUAL❑ 10 MOTESTINGHLY TANK ❑ 95 UNKNOWN ❑99 OTHER VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) 1.ESTIM TEDD T USE M AV/YR) 2.ESTIMATED QUANTITY OF SUBSTANCE REMAINING 3.WAS TANK FILLED WITH YES [:] NO GALLONS INERT MATERIAL 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 A SIGNATURE) LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION ICTION a FACILITY# TANK N STATE I.D.# I-I PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE a- THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORM A,UNLESS A CURRENT FORMA HAS BEEN FILED. FORM C MUST BE COMPLETED FOR INSTALLATIONS. THIS FORM FORME (6-95)SHOULD BE ACCOMPANIED BY A PLOT If FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THWE�ROUI STORAGE TANK S