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• STATE OF CALIFORNIA • STATE WATER RESOURCES CONTROL BOARD .,,c�+ UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B ,"� LL m COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. " MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ONSITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: U gZ0 gT. Gpd I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A OWNER'S TANK 1.D.# o I B. MANUFACTURED BY: C. DATE INSTALLED(MO/DAV/YEAR) v, )of:,, D. TANK CAPACITY IN GALLONS: If.TANK CONTENTS IFA-1 IS MARKED,COMPLETE ITEM C. A 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C 1a REGULAR UNLEADED ❑ 3 DIESEL ❑ 6 AVIATIONGAS ❑ 2 PETROLEUM ❑ 80 EMPTY I�Q 1 PRODUCT 1b PREMIUM UNLEADED ❑ 4 GASAHOL ❑ 7 METHANOL ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 1C MIDGRADE UNLEADED ❑ 5 JET FUEL ❑ 8 M85 ❑ 2 LEADED ❑ 99 OTHER(DESCRIBE IN TEM 0.BELOW) D. IF(A-1)IS NOT MARKED, ENTER NAME OFSUBSTANCE 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 ❑ 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 5 INTERNAL BLADDER SYSTEM ❑ 95 UNKNOWN SYSTEM g�❑qq 2 SINGLE WALL FL-j-4 SINGLE WALL IN A VAULT ❑ 99 OTHER u B. TANK \, BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ B 10096 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 ❑ 8 UNLINED /{.� 95 UNKNOWN ❑ 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? "YEAS_ NO— D.EXTERIOR ❑ 1 POLYETHYLENE WRAP2 COATING CORROSION ❑ ❑ 3 VINYL WRAP ❑ d FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE n%5 UNKNOWN ❑ 99 OTHER E.SPILL AND OVERFILL,BIC. SPILL CONTAINMENT INSTIALLED 11'EAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) DROP TUBE YES_ NO_ STRIKER PLATE VES_ NO_ DISPENSER CONTAINMENT YES_ NO_ IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A<r,) SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION <05h 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 A U 7 STEEL W/COATING A U 8 1001/6 METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A(V5 UNKNOWN A U 99 OTHER D. LEAK DETECTION 1 WO m UNE IFAK ❑2 UNE TKIMNE55 O 3 COMINUWS INTERSTIIAL d ELECIROmC LINE O 5 AUTOMATIC PUMP MOR TESTING MOMTORRlG LEAK OEIECTOR SHUTDOWN El 99 OTKR V.TANK LEAK DETECTION I VISUAL CHECK❑ 7 CONTINUOUS INTERSTITIAL 2 MANUAL RECONCILIATION MONITORING ❑ 3 MONIITORING OZE ❑ 4 AUTOMATGAUGING MONITORING TANK ❑ 5 GROUND MONTORING�R a TNNES UALTANK NG MONITORING ❑ B SIR ❑ 9 WEEK LY MANUAL ❑ 10 MOTESTINGHLY TANK ❑ 95 UNKNOWN 99 NG OTHER VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE N.PLACE) 1.ESTIMATED DATER)( /DAV/YR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH 47 SUBSTANCE REMAINING V GALLONS INERT MATERIAL? YES ❑ NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT TANK OWNER'S NAME (PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY# r5 TANK# STATE LDS COUNTY � PERMIT NUMBER PERMIT APPROVED BV/DATEHERMIT EXPIRATION DATE THIS FORM MUST BE ACCOMPANIED BY PERMIT APPLICATION FORM A,UNLESS A CURRENT FORMA HAS BEEN FILED. FORM C MUST BE COMPLETED FOR INSTALLATIONS.THIS FORM FORM B (6-95)SHOULD BE ACCOMPANIED BY A PLOT PLIfLE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE&GROUND STORAGE TANK REGULATIONS