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• STATE OF CALIFORNIA • ^`^� .� STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY 7 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED O E ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT E] 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: 1. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A OWNER'S TANK I.D.p B. MANUFACTURED BY: An N wrl C. DATE INSTALLED(MO/DAY/YEAR) D. TANK CAPACITY IN GALLONS: II.TANK 9ONTENTS IFA-1 IS MARKED,COMPLETE ITEM C. (� A. EIrl MOTOR VEHICLE FUEL ❑ 4 OIL B. / C. 1a REGULAR UNLEADED ❑ 3 DIESEL E] 6 AVIATION GAS ❑ 2 PETROLEUM 80 EMPTY LLLLlIJJJ 1 PPRODUCT Imo( ib PREMIUM UNLEADED ❑ 4 GASAHOL E:] 7 METHANOL 11A'1 ❑ ❑ lo 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 10 MIDGRADE UNLEADED ❑ 5 JET FUEL ❑ 8 M85 ,/A) ❑ 2 LEADED ❑ 99 OTHER(DESCRIBE IN ITEM D.BELOW) C`I:JJf 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 E A. TYPE OF ❑ 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 5 INTERNAL BLADDER SYSTEM 95 UNKNOWN SYSTEM ❑ 2 SINGLE WALL ❑ 4 SINGLE WALL IN A VAULT ❑ 99 OTHER S. TANK ❑ 1 BARE STEEL ❑ 2 STAINLESS STEEL 3 FIBERGLASS 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ' 1ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP (Primary Teck) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL (��/95 UNKNOWN ❑ 99 OTHER C.INTERIOR 1 RUBBER LINED E] 2 ALKYD LINING E�l3 PDXV LIE]NING 4 PHENOLIC LINING LINING OR ❑ 5 GLASS LINING ❑ 8 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 ❑ 91 NONE KNOWN ❑ 99 OTHER E.SPILL AND OVERFILL,810. SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) DROP TUBE 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 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 2DOUBLE WALL A U 3 LINED TRENCH A U5 UNKNO 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 A Ueyr—UNK—N—Ob A U 99 OTHER D. LEAK DETECTION 1 LM MECE UUK 2 LINE TK:mNESS 3 CONTINUWS INrERSmNL 4 EISMIMIC UNE 5 AVOWTIC WAP DETECTORWMCII rES7rNG MONTONMG ❑ LEAK DETECTOR ❑ SMITDOWN ❑ 99 OTHER V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 MANUAL ANNUAL RECONCILIIATIONORY ❑ 3 VAOZEMONIITORING ❑ 4 GAUGINGAUTOMATIC TANK ❑ 5 GROUND WATEMONITORING R ❑ 6 TESTINGTANK ❑ 7 MON TOROUS INTERSTITIAL 8 SIR ❑ 9 ANEK GAUGANGAL ❑ 10 MONTHLY TANK ❑ 95 UNKNOWN E:]99 OTHER VI.TAN OSURE INFORMATIO (PERMANENT CLOSURE IN-PLACE) 1.E MATED TATE rT USED(MO/DAY/YR 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH SUBSTANCE REMAINING GALLONS INERT MATERIAL? YES NO THIS FORM HAS BEEN COYPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT TANK OWNER'S NAM DATE INTO 8 SIGN LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW STATE I.D:# COUNTY If JURISDICTION# FACILITY It G TANK k m I PERMIT NUMBER PEflM1T APPROVED BVA]ATE PERMIT E%PIflA THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED, FORM C MUST B C M ETED FOR INSTALLATIONS. THIS FORM SHOULD BE ACCOMPANIED BY A PLOT PLAN. FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS FORM 8 (6.95)