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STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B 1 COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ❑ i NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION �❑ 7 PERMANENTLY CLOSED O ONE ITEM ❑ 2 INTERIM PERMIT 714 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE B TANK REMOVED O DBA OR FACILITY NAME WHERE TANK IS INSTALLED: Ed "SItO I. TANK DESCRIPTION COMPLETE ALL ITEMS— SPECIFY IF UNKNOWN A OWNER'S TANK I.D.# B. MANUFACTURED BY: C. DATE INSTALLED(MO/DAYNEAR) D. TANK CAPACITY IN GALLONS: II.TANK CONTENTS IFA-1 IS MARKED,COMPLETE ITEM C. A ❑ I MOTOR VEHICLE FUEL ❑ 4 OIL B.�,/ C. ❑ 1a REGULAR UNLEADED 3 DIESEL ❑ 6 AVIATION GAS 2 PETROLEUM ❑ BO EMPTY IJ'.L I PRODUCT ❑ 1b PREMIUM UNLEADED ❑ d JET FUEL ❑ 8 METHANOL ;s` /—�� ❑ 1C MIDGRADE UNLFADEO ❑ 5 JEf FUEL ❑ B M85 ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ p LEADED ❑ 99 OTHER(DESCRIBE IN ITEM D.BELOM D. IF(A1)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 I❑ 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 B. TANK I BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ B 100% METHANOL COMPATIBLE W/FRP (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 `�Xr6 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH WON. METHANOL? YES_ N04 D.EXTERIOR ❑ 1 POLYETHYLENE WRAP 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC CORROSION PROTECTION ❑ 5 CATHODIC PROTECTION ❑ ❑ ❑g1 NONE 95 UNKNOWN 99 OTHER SPILL CONTAINMENT INSTAlLEO YEAR) OVER FILL PREVENTION gQUIPMENT INSTALLED(YEAR) E.SPILL AND OVERFILL,Bio. DROP TUBE YES_ NO ST IKER 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 A01 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION A1 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 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 A07 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 0. LEAK DETECTION E]1 MECHNN=L UNE IF. 2 UNE MWM S$ 3 CINUOUS IMlitmRIAL d EIE=MIC LINE ❑5 AInOMATG PUMP G uolt TEsnuG ❑ OM MOVORING ❑ LMK OETELTOR sxumowN gg OTHER V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 RECONCILIATION ORY ❑ 3 VADOZEMONITORING ❑ 4 GAUGING MONITORING TANK ❑ 5 GROUND MONTORINGTER ❑6 ANNUALTESTING ❑ 7 CONMON INUOU INTERSTITIAL ❑ 8 SIR ❑ 9 WEEK LY MANUAL ❑10 MONTHLY TANK E] 95 UNKNOWN ❑ 99 OTHER ORIN VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PUCE) ESTIMATED T LAAi D(MOIDAYNR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH 1. 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 CORRE T TANK OWNER'S NAME DATE (PRINTED 8 SIGNATURE) LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY#3 TANK# STATE I.D.# m b 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 FILED. FORM C MUST BE COMPLETED FOR INSTALLATIONS.THIS FORM SHOULD BE ACCOMPANIED BY A PLOT f FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTINGTH ERGROUND STORAGE TANK REGULATIONS FORM B (6.95) ? Ory O`1P,('l(I/CpJ