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• 0 STATE OF CALIFORNIA p"�s `i STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B �d� COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT O 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION 5C7 PERMANENTLY CLOSED ON SITE ONE TEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: 0941- STATE Pi9CKE2S I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A OWNER'S TANK I.D.# OD 2 B. MANUFACTURED BY: C. DATE INSTALLED(MO/DAYNEAR) �J�Jf[,-�(� � D. TANK CAPACITY IN GALLONS: 'LGY.AV [I.TANK CONTENTS IF A-1 IS MARKED,COMPLETE ITEM C. I MOTOR A 2 PETROLEUM 80 FUEL O 800IL EMPTY B ❑ 1 PRODUCT C �lREGULAR UNLEADED ❑ 3 DIESEL [:] 6 AVIATION GAS lb PREMIUM UNLEADED ❑ 4 GASAHOL E:j ] METHANOL 8 M85 E:] ED ❑ ❑❑ 2 LEARADE UNLEADED Q 99 JET FUELOTHER (DESCRIBE[::] DESCR❑IBE IN ITEM 0.BELOW) 3 CHEMICAL PRODUCT 95 UNKNOWN 2 WASTE 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 A. TYPE OF F-] DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 5 INTERNAL BLADDER SYSTEM ❑ 95 UNKNOWN SYSTEM IL-A 2 SINGLE WALL ❑ 4 SINGLE WALL IN A VAULT ❑ 99 OTHER B. TANK Ley 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 1001/6 METHANOL COMPATIBLE W/FRP (PHmary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER C.INTERIOR ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY UNING ❑ 4 PHENOLIC LINING LINING OR ❑ 5 GLASS LINING r�4 6 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO— D.EXTERIOR ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC CORROSION PROTECTION ❑ 5 CATHODIC PROTECTION 15jr 91 NONE ❑95 UNKNOWN ❑ 99 OTHER E.SPILL AND OVERFILL,6IC. SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) DROP TUBE YES NO_ STRIKER PLATE YES NO Je DISPENSER CONTAINMENT YES NO-Ll— IV. LIV.PIPING INFORMATION CIRCLE A IFABOVEGROUNDOR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A(Z 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION A(p SINGLE WALL A U 2DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND AQ1 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 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 O. LEAK DETECTIONI MECN GAL LINE IE 2 MUKTNEss WWS w Snnu ❑4 ELECTRONIC LINE 5 AuroMAnc RUNw ❑ GETECIOR 1E6 NGNE TIG ❑3 ca MOMTORING LEAK DETECTOR ❑ SH0100WN ❑ 99 OIHER V.TANK LEAK DETECTION � F-11 VISUAL CHECK L9 2 MANUAL INVENTORY ❑ 3 ION VADOZE ❑ 4 GAUGINGIC TANK ❑ 5 MONITORING DWATER �6 ANNUALTANK ❑ 7 CONTINUOUS MONITORING INTERSTITIAL O 8 SIR ❑ 9 T EEK GAUGIN UAL ❑10 MONTHLYTESTING TANK ❑ 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PI-ACE) 1.ESTIMATED Dr SED AAY/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 6 SIGNATURE) w_ v a ' / LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBUM BELOW COUNTY# JURISDICTION# FACILITY# TANK# STATE I.D:# m T�Q0 PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE 0 THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICAD�TION-FORM A,UNLESS A CURRENT FORMA HAS BEEN FILED. FORM C MUST BE COMPLETED FOR INSTALLATIONS. THIS FORM SHOULD BE ACCOMPANIED BY A PLOT PWLE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE0RGROUND STORAGE TANK REGULATIONS FORM B (6.95)