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• STATE OF CALIFORNIA • ,?�� )o*� 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 CLOSED ON SITE ONE REM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: Z o 1 AE . I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A OWNER'S TANK I.D.# a B. MANUFACTURED BY: Y -� C. DATE INSTALLED(MOADAWYEAR) (/fY0. TANK CAPACITY IN GALLONS: - U II,TANK CONTENTS IF A-1 IS MARKED,COMPLETE ITEM C. A. MOTOR VEHICLE FUEL ❑ 4 OIL B. C. la REGULAR UNLEADED ❑ 3 DIESEL ❑ 6 AVIATION GAS �1b PREMIUM UNLEADED ❑ 4 GASAHOL ❑ 7 METHANOL �2 PETROLEUM ❑ 80 EMPTY �1 PRODUCT ❑ tc MIDGRADE UNLEADED ❑ 5 JET FUEL ❑ 8 M85 ❑ 3 CHEMICALPRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED ❑ 99 OTHER(DESCRIBE IN ITEM 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 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 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 ❑ 6 100% METHANOL COMPATIBLE WAFRP (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 LININGOR ❑ 5 GLASS LINING ❑ 6 UNLINED 1Y95 UNKNOWN ❑ 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? `YYEE"S_ NO— D.EXTERIOR O_D•EXTERIOR ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC CORROSION ❑ 91 NONE 95 UNKNOWN ❑ 99 OTHER PROTECTION ❑ 5 CATHODIC PROTECTION SPILL CO NTXINMENT INSTALLED((YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) E.SPILL AND OVERFILL,BLC. DROPTUSE 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 FLEXIBLEPIPING A U 99 OTHER B. CONSTRUCTION i SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH 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 A U 757,�,�yJW/COATING A U 8 100% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A(�i95 UNKNOWN A U 89 OTHER 1 MECHMACAL NNE LEAK 2 SIE iMJRNESS 3 COmIN11W3 INTRISmIAL 4 ELECmONIC NNE ❑5 AIROIMTIC NAP ❑ 99 OTHER D. LEAK DETECTION ❑ oEr9croR ❑ TEmxc ❑ MoxrtoRwc ❑ lENXDETECTOR sluloovm V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 RECONCILIATIONMANUAL ORY ❑ 3 MONITORING ❑ 4 AUTOMATGAUGINGIC TANK ❑ 5 GROUND MONITORING TESTING❑6 ANNUALTESTINGTANK ❑ 7 CONTINUOUS TEST INTERSTITIAL E::] 8 SIR WEEKLY MANUAL ❑10 MONTHLY ONHL TANK [:] 95 UNKNOWN ❑99 OTHER MONITOR NG VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) 1.ESTIMATED DATE L#ST US MO AY/YR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES ❑ NO❑ SUBSTANCE REMAINING GALLONS 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 8 SIGNATURE) LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY# TANK# E:fSTATE I.D.# oPERMIT NUMBER PERMIT APPROVED BYIDATE PERMIT EXPIRATION DATE re THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLQIITION.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 RLE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING T)*ERGROUND STORAGE TANK REGULATIONS FORM B (6.95)