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STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B Itl COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLO ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVE DBA OR FACILITY NAME WHERE TANK IS INSTALLED: I. TANK DESCRIPTION COMPLETE ALL ITEMS— SPECIFY IF UNKNOWN A OWNER'S TANK I.D.a W r ( JN B. MANUFACTURED BY: C. DATE INSTALLED(MO/DAYNEAR) D. TANK CAPACITY IN GALLONS: II.TANK CONTENTS IF A-1 IS MARKED,COMPLETE ITEM C. _ r INLEADEO ❑ 3 DIESEL ❑ 6 AVIATION GAS A ❑ 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. r` 4LEADED ❑ 4 GASAHOL ❑ 7 METHANOL ❑ 2 PETROLEUM ❑ 80 EMPTY NLEADED ❑ 5 JET FUEL ❑ 8 M85 ❑ 3 CHEMICALPRODUCT ❑ 95 UNKNOWN �/ ❑ 99 OTHER(DESCRIBE IN ITEM D.BELOW) S� C.A.S.a: D. IF(A.1)IS NOT MARKED. ENTER NAME OF SUBSTANCE STORED III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.8, �i DOUBLE WALL ❑ 3 SINGLE WALL 1 0 TERNAL BLADDER SYSTEM ❑ 95 UNKNOWN A. TYPE Of ❑ 4 SINGLE WALL THER SYSTEM ❑ 2 SINGLE WALL �1 BARE STEEL ❑ 2 STAINLESS STE _...LASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B. TANK MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLUrnOE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING ASI C.INTERIOR ❑ 95 UNKNOWN �99 OTHER �1 R- -s 'P LINING OR ❑ 5 GLASS LINING ❑ 8 UNLINED COATING IS LINING MATERIAL COMPATIBLE WITH 100°.6 METHANOL? YES_ NO— D.EXTERIOR ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC CORROSION 95 UNKNOWN 99 OTHER PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE ❑ SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PflEVENTION EQUIPMENT INSTALLED(YEAR) E.SPILL AND OVERFILL,6IC. DROP TUBE YES_ NO_ STRIKERPLATE YES_ NO__ DISPENSER CONTAINMENT YES_ NO IV.PIPING INFORMATION CIRCLE AIFABOVE GROUND ORU)FUNDERGROUND,BOTH IFAPPUCABLE A. SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLEPIPING A U 99 OTHER B. CONSTRUCTION A U 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 SAKE 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 7 STEEL W/COATING A U B 100% METHANOL COMPATIBLE WIFRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER 1 MELHNafAL UNE LEAK 2 UNE TKiaTNE55 ❑3 CONTINUWS INTERSTM& E 4 ELECIROMC UNE ❑5 AVfOMALIC PUMP ❑ 99 OTHEfl D. LEAK DETECTION ❑ DM6iOR ❑ iEsluw MONITORIxe LEAK OETECiOR SMITOONN V.TANK LEAK DETECTION Vied ev -RooF TLS-3S0 ❑ 1 VISUAL CHECK ❑ 2 MANUAL RECONCI INVENTORY ❑ 3 ON MONITORING 4 GAUGINAUTOMATG MONITORING TANK ❑5 MONTORINGGROUND TER ❑6 TESTINGANNUAL ❑ 7 MONG N INUOU INTERSTITIAL ❑ 8 SIR ❑ 9 WEEKLY MANUAL ❑10 MONTHLY TANK ❑ 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PUCE) 1.ESTIMATED DATE LAST USED(MOIDAYN 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES E] 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 DATE TANK OWNER'S NAME � 1 (PRINTED A 61GNATUREI T0-S � C_r 16 VA LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY# TANK STATE 01 m PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE THIS FORM MUST BE ACCOMPANIED BY A PERMIT APP LI N-FORM A,UNLESS A CURRENT FORMA HAS BEEN FILED. FMUST BE COMPLETED FOR INSTALLATIONS.THIS FORM SHOULD BE ACCOMPANIED BY A PLOT PILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE GROUND STORAGE TANK REGULATIONS FORMS (6.95)