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• • STATE OF CALIFORNIA J a STATE WATER RESOURCES CONTROL BOARD 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 CLO O ONE REM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE 8 TANK REMOVED 17 DBA OR FACILITY NAME WHERE TANK IS INSTALLED: �G I. TANK DESCRIPTION COMPLETE ALL ITEMS— SPECIFY IF UNKNOWN A OWNER'S TANK I.D.p B. MANUFACTURED BY: C. DATE INSTALLED(M (DAY/EAR) D. TANK CAPACITY IN GALLONS: e9 a-tll II.TANK CONTENTS IF A-1 IS MARKED,COMPLETE ITEM C. ❑ to REGULAR UNLEADED DIESEL ❑ 6 AVIATION GAS A ❑ 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C' ❑ 1b PREMIUM UNLEADED ❑ ❑ �/ 4 GASAHOL 7 METHANOL PETROLEUM ❑ 80 EMPTY Ix1 PRODUCT ❑ 1C MIDGRPDE UNLEADED ❑ 5 JETFUEL ❑ B M85 ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN f�❑��`2 WASTE ❑ 2 LEADED ❑ 99 OTHER(DESCRIBE IN REMD.BELOM D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S.p: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.S.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 (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER C.INTERIOR ❑ 1 RUBBER LINED ❑ 22 ALKYO LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING LINING OR ❑ 5 GLASS LINING UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER COATING IS LINING MATERIAL COMPATIBLE`WIIT�H 100% METHANOL? YES_ NOS\ D.EXTERIOR ❑ 1 POLYETHYLENE WRAP X2 COATING E] 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC CORROSION 99 OTHER PROTECTION 91 NONE 95 UNKNOWN❑ 5 CATHODIC PROTECTION ❑ ❑ ❑ SPILLCONINNMENTINSTALLED R) OVERFILL PREVENTID QUIPMENT INSTALLED(YEAR) E.SPILL AND OVERFILL,8L6. DROP TUBE YES_ NO ST KER 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 01 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION A I&> 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 A U 5 ALUMINUM A U 6 CONCRETE ACL> STEEL W/COATING A U 8 100% METHANOL COMPATIBLEWIFRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION ED1 MEGUN'IGL UNE LEAK 2 UNE TIGHTNESS 3 COMINLWS INTERSTRIAL ❑4 ELECTRONIC UNE ❑5 AUfOMAnC PUMP 99 OTHER ME90H ❑ TESnNo ❑ MONRORING LE4N DETECnIR s6uToowx V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 RMANUAL ECONCILNTENONORY ❑ 3 MONITORING ❑ 4 AUTOMATIGAUGING MONITORING TANK [:] 8 GROUND MONITORINGTER ❑ TANK VADOZE8 TESTING ❑ 7 MON TORNG INTERSTITIAL ❑ 8 SIR ❑ 9 WEEKLY K ANUAL ❑10 MOSNTHLY TING TANK E] 95 UNKNOWN ❑99 OTHER VI,TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) 1.ESTIMATED DATE LAST USED(MOIDAYNR) 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 OF MY KNOWLEDGE, IS TRUE AND CORRECT TANK OWNER'S NAME DATE (PRINTED a SIGNANRE) LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY p JURISDICTION It FACILITY p TANK p STATE I.D.# m PERMIT NUMBER PERMIT APPROVED BYIDATE PERMIT EXPIRATION DATE 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 SHOULD BE ACCOMPANIED BY A PLOT P LE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE RGRDUUND STORAGE TANK REGULATIONS FORM B (6-95)