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• STATE OF CALIFORNIA �`'�..��' <br /> o' <br /> STATE WATER RESOURCES CONTROL BOARD '" o <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B e <br /> COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM, <br /> MARK ONLY E2f 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSE SI E <br /> ONE REM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED <br /> DBA OR FACILITY NAME WHERE TANK IS INSTALLED: <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS– SPECIFY IF UNKNOWN O <br /> A OWNER'S TANK I.D.X B. MANUFACTURED BY: yew ry�-� <br /> C. DATE INSTALLED(MOTDAY%EAR) !I D. TANK CAPACITY IN GALLONS: is-0/ • /' ,/� <br /> IL TANK C NTENTS IFA-1 IS MARKED,COMPLETE ITEM C. J 5 N <br /> A 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C. 1a REGULAR UNLEADED ❑ 3 DIESEL ❑ 6 AVIATION GAS <br /> EMPTY vI� <br /> ❑ 2 PETROLEUM ❑ 80 E ❑ 1 PRODUCT ❑ Ib PREMIUM UNLEADED ❑ 4 GASAHOL ❑ 7 METHANOL <br /> ❑ 3 CHEMICALPRODUCT ❑ 95 UNKNOWN ❑ 2 yyg575 ❑ 1c MIDGRADE UNLEADED ❑ 5 JET FUEL ❑ 8 M85 <br /> ❑ 2 LEADED ❑ 99 OTHER(DESCRIBE IN REM D.BELOR9 <br /> D. IF(A.1)IS NOT MARKED, ENTER NAME OFSUBSTANCE STORED C.A.S.N: <br /> III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A,B.AND C.AND ALLTHAT APPLIES IN BOX D AND E <br /> A. TYPE OF ❑ 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER 5 INTERNAL BLADDER SYSTEM 95 UNKNOWN <br /> SYSTEM ❑ 2 SINGLE WALL ❑ 4 SINGLE WALL IN A VAULT ❑ 99 OTHER <br /> B. TANK ❑ I BARE STEEL 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC <br /> MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE 07 9LUMINUM ❑ 8 100% METHANOL COMPATIBLE WIFRP <br /> (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL L`� 95 UNKNOWN ❑ 99 OTHER <br /> C.INTERIOR ❑ I RUBBER UNED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING <br /> LINING OR r_15 GLASS LINING 6 UNLINED 95 UNKNOWN ❑ 99 OTHER <br /> COATING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO— <br /> D.EXTERIOR ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC <br /> CORROSION <br /> PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE 95 UNKNOWN ❑ 99 OTHER <br /> E.SPILL AND OVERFILL,BIC. SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) <br /> DROP TUBE YES_ NO_ STRIKER PLATE YES_ NO_ DISPENSER CONTAINMENT YES_ NO <br /> IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND,BOTH IF APPLICABLE <br /> A. SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER <br /> B. CONSTRUCTION A U I SINGLE WALL A U 2DOUBLE WALL A U 3 LINED TRENCH A U 9 UNKNOW A U 99 OTHER <br /> C. MATERIAL AND A U 1 BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A U 4 FIBERGLASS PIPE <br /> CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL W/COATING A U B 100% METHANOL COMPATIBLE W/FRP <br /> PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U UNKNOW A U 99 OTHER <br /> D. LEAK DETECTION 1 MECNMIICAL LINE IF.AI( ❑2 UNE TNiH1 W EJ 3 CMINUWS INTERSnnAI ❑4 ELECmONiC UNE 5 AumlunC PUMP <br /> OEiECfOq TESTING MOMTmm LEAN CEIECMA ❑ SHUTDOWN 99 OTHER <br /> V,TANK LEAK DETECTION <br /> ❑ 1 VISUAL CHECK ❑ 2 MANUAL L VENTORY E] 3 VADOZE <br /> RION MONITORING 4 GAUGING C TANK ❑ 5 MONITORING D WATER E:]6 ANNUAGTANK <br /> 7 <br /> MONITORING NUOUS INTERSTITIAL � 8 SIR ❑ 9 WEEK LY MANUAL E::] 10 MOTESTINGHLY TANK 95 UNKNOWN E:] 99 OTHER <br /> VI.TANK CLOSU MATION(PERMANENT CLOSURE IN-PLACE) <br /> 1.ESTIM D TE LAIT USED( /DAY ) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH <br /> SUBSTANCE REMAINING GALLONS INERT MATERIAL 7 YES ❑ NO❑ <br /> TH FO HA BEEN COMP ED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT <br /> TAN DATE <br /> (PRINTED 8 SIGNATURE) <br /> LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW <br /> STATE I.D:# <br /> COUNTY N JURISDICTION F FACILITY k TANK a <br /> m WMa D <br /> PERMIT NUMBER PERMIT APPROVED BYIDATE PERMIT EX T O W <br /> THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. FORM C MUST BE COMPLETED FOR INSTALLATIONS. THIS FORM <br /> SHOULD BE ACCOMPANIED BY A PLOT PLAN. FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> FORM B (6-95) <br />