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• iso .cey STATE OF CALIFORNIA c�6 STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B 1 COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLO ED ONSITE ONE REM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED / DBA OR FACILITY NAME WHERE TANK IS INSTALLED: 6 5'. S'a/ DOL Ste• I. TANK DESCRIPTION COMPLETE ALL ITEMS— SPECIFY IF UNKNOWN B. MANUFACTURED BY: U• fes+ r A OWNER'S TANK I.D.# D. TANK CAPACITY IN GALLONS: Q 0 C. DATE INSTALLED(MO/DAYNEARj II.TANK CONTENTS IF A-1 IS MARKED,COMPLETE ITEM C. ❑ to flEGULAfl UNLEADED ❑ 3 DIESEL ❑ 8 AVIATION GAS A. ❑ 1 MOTOR VEHICLE FUEL 4 OIL B. C ❑ 10 PREMIUM UNLEADED ❑ 4 GASAHOL ❑ 7 METHANOL ❑ 2 PETROLEUM 80 EMPTY 1 PRODUCT ❑ 1C MIDGRADE UNLEADED ❑ 5 JETFUEL ❑ 8 MB5 ❑ 3 CHEMICALPRODUCT ❑ 95 UNKNOWN 2 WASTE ❑ 2 LEADED 99 OTHER(DESCRIBE IN ITEM D.BELOW) 0. IF(A1)ISNOTMARKED, ENTER NAME OF SUBSTANCE STORED�FjA�/ O/ A.S.#: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.S.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 K 95 UNKNOWN SYSTEM ❑ 2 SINGLE WALL ❑ 4 SINGLE WALL IN A VAULT ❑ 99 OTHER [:] 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B. TANK ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE MATERIAL E] 5 CONCRETE (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL 95 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING C.INTERIOR ❑ 6 UNLINED 95 UNKNOWN ❑ 99 OTHER LINING OR ❑ 5 GLASS LINING COATING IS LINING MATERIAL COMPATIBLE WITH 100°/6 METHANOL? ES_ NO— D.EXTERIOR ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC CORROSION 91 NONE 5 UNKNOWN ❑ 99 OTHER PROTECTION ❑ s CATHODIC PROTECTION ❑ SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) E SPILL AND OVERFILL,8[0. pg0p TUBE VES_ 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 U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL A U 2 DOUBLE WALL A U 3 UNED TRENCH A(2�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 8 100% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION 5 UNKNOWN A U 99 OTHER 1 MECHMUCAL UNE IEAK2 UNE HTNESS ❑3 COMINUOIIS INTERS k ❑4 EU MONIC UNE 5 AUPONNTIC PUMP 99 OTHER U' D. LEAK DETECTION ❑ DETECTOR ❑ TM TMW MONITORING LEAK TK:.TEGTGR sxuloowN V.TANK LEAK DETECTION GROUND❑ 1 VISUAL CHECK ❑ 2 RECONCILATIONORY ❑ 3 VADOZEMONITORING ❑ 4 GAUGNGAUTOMATIC TANK ❑ 5 MONTORINGTER ❑8 ANNUAL TESTING ❑ 7 MON TOR NG INTERSTITIAL ❑ 8 SIR ❑ 9 TANK GAUGINGTESTING WEEKLY MANUAL ❑10 Y TANK 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES E] NO i.ESTIMATED DATE LAST USED(MO/DAYNR) 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 (PRIN1TE04 SIGNATURE) LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# TANK# C� STATE I.D.# 0 in u �6 s PERMIT NUMBER PERMIT APPROVED BY/DATE RMIT EXPIRATION DATE THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLIC ON-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. FORM C MUS?BE COMPLETED FOR INSTALLATIONS. THIS FORM SHOULD BE ACCOMPANIED BY A PLOT PILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THEORGROUND STORAGE TANK REGULATION (� FORM B (6-95) 1