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• � VnCY! STATE OF CALIFORNIA .,P '!6V Cif STATE WATER RESOURCES CONTROL BOARD W,,, 6 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 6 TEMPORARY TANK CLOSURE `TSB TANK REMOVED O DBA OR FACILITY NAME WHERE TANK IS INSTALLED: -Sff� ��G I. TANK DESCRIPTION COMPLETE ALL ITEMS– SPECIFY IF UNKNOWN A OWNER'S TANK I.D.# B. MANUFACTURED BY: C. DATE INSTALLED(MO/DAV/YEAR) D. TANK CAPACITY IN GALLONS: II.TANK CONTENTS IFA-1 IS MARKED,COMPLETE ITEM C. A F-1 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C. ❑ to REGULAR UNLEADED 3 DIESEL ❑ 6 AVIATION GAS ��'' 1�/ ❑ 1b PREMIUM UNLEADED GASAHOL ❑ 7 METHANOL u PETROLEUM ❑ 80 EMPTY �7 1 PRODUCT ri'%% ❑ 1c MIOGRADE UNLEADED ❑ 5 JET FUEL ❑ e M85 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED ❑ 99 OTHER(DESCRIBE IN REM D.BELOW) 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 ❑ 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR UNER ❑ 5 INTERNAL BLADDER SYSTEM ❑ 95 UNKNOWN SYSTEM 2 SINGLE WALL ❑ 4 SINGLE WALL IN A VAULT ❑ 99 OTHER S. TANK #^�LJ�/ 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL IJ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 1001/6 METHANOL COMPATIBLE WIFRP (Primary 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 6 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER COATING IS LINING MATERIAL COMPATIBLEEWWI/ 100°16 METHANOL? YES— NOS.\ D.EXTERIOR ❑ 1 POLYETHYLENE WRAP IXI 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC CORROSION 91 NONE 95 UNKNOWN ❑ 99 OTHER PROTECTION ❑ 5 CATHODIC PROTECTION ❑ ❑ SPILL CONTAINMENT INSTALLED(NEAR) OVERFlLL PREVENTION EQUIPMENT INSTALLED(NEAR) DROP TUBE YES_ NO DISPENSER CONTAINMENT YES_ NO� E.SPILL AND OVERFILL,etc. No R ER PLATE VES 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 FLEXIBLEPIPING A U 99 OTHER B. CONSTRUCTION A 1 SINGLE WALL A U 2 DOUBLE WALL A U 3 UNED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND A U i 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 1)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 i MECWWIC4 UNE IFN( ❑2 ONE BGMNESS 3 CIXmM10US INTERSTIMI 4 BECTRGNIC LINF ]5 AUTOMATIC PUMP 99 OTHER pETECOR TESTING NOMTCRRIG IFAK OETECmn SXUTGONN V.TANK LEAK DETECTION E] 1 VISUAL CHECK ❑ 2 RECONCIUATIONINVENTORY ❑ 3 VADOZEMONITORING ❑ 4 AUTOMATGAUGING IC TANK ❑5 GROUND MONITORING TER ❑ 8 iESTTANK ING ❑ 7 MON INU UG INTERSTTIAL ❑ 8 SIR 9 WEEKLY MANUAL E]10 MOTESTINGHLY 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 FlLLEO WITH YES ❑ NO _ SUBSTANCE REMAINING 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 GATE (PRINTED a 61GNATURE) LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY If JURISDICTION# f�FACILITY�# TANK# STATE I.D.# = L J _.I__� �J _ -0 3 PERMIT NUMBER I 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 FILED. FORM C MUST BE COMPLETED FOR INSTALLATIONS.THIS FORM SHOULD BE ACCOMPANIED BY A PLOT PFILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE ERGROUND STORAGE TANK REGULATIONS FORM B (6-95)