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• • i STATEOF CALIFORNIA - o STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION FORM B COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED on,�I�E 1 NEW PERMIT ❑ 3 RENEWAL PERMIT Ir•!1//N1 [MARK 4 AMENDED PERMIT6TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED2 INTERIM PERMIT DBA OR FAC ILRY NAME WHERE TANK IS INSTALLED: I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN B MANUFACTURED BV' A OWNERS TANK I.D.# D. TANK CAPACITY IN GALLONS: ��0 C. DATE INSTALLED(MOIDAYNEAR) n II.TANK 9ONTENTS IF A-1 IS MARKED,COMPLETE ITEM C. to REGUUR U rtEADED ❑ 3 DIESEL ❑ B AVIATION GAS 1 MOTOR VEHICLE FUEL ❑ 4 OIL B- C 1b PREMIUM UNLEADED ❑ 4 GASAHOL ❑ 7 METHANOL A ❑ 2 PETROLEUM ❑ 80 EMPTY 1 PRODUCT ❑ 1c IADGPADE UNFADED ❑ 5 JET FUEL ❑ 5 MSS 2 WASTE 2 LEADED ❑ 99 OTHER MCRSE IN DEM O.SELOVO ❑ 3 CHEMICALPROOUCT ❑ 95 UNKNOWN ❑ ❑ C.AS.#: D. IF(At)IS NOT MARKED. ENTER NAME OF SUBSTANCE STORED III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.B.AND C.AND ALL THAT APPLIES IN BOX D AND ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 5 INTERNAL BLADDER SYSTEM 95 UNI(NOWN F-1 1 DOUBLE WALL ❑ 99 OTHER A. TYPE OF ❑ 4 SINGLE WALL IN A VAULT SYSTEM ❑ 2 SINGLE WALL S. TANK ❑ t BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD WIFlSERGLASS REINFORCED PLASTIC ❑ 8 POLYVINYL CHLORIDE =17 UMINUM ❑ S 100% METHANOL COMPATIBLE W/FRP MATERIAL ❑ 5 CONCRETE (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL I—I 95 UNKNOWN ❑ 99 OTHER ❑ 2 ALKYD UNING 3 POKY LINING ❑ 4 PHENOLIC LINING C.INTERIOR ❑ 1 RUBBER LINED ❑ ❑ 99 OTHER LINING OR F1 GLASS LINING 8 UNLINED 95 UNKNOWN COATING IS UNING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO— D.EXTERIOR ❑ 1 POLYETHYLENE WRAP 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC CORROSION91 NONE UNKNOWN ❑ 99 OTHER PROTECTION ❑ s CATHODIC PROTECTION ❑ SPILL CONTAINMENTINSTALLED(YEAR) OVERFILL PREVENTION EOUIPMFNTINSTALLED(YEAR) IF—SPILL AND OVERFILL,ete. DROP TueE 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 U 2 PRESSURE A U 3 GRAVITY A U a FLEXIBLE PIPING A U 99 OTHER A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 5 UNKNOW A U 99 OTHER S. CONSTRUCTION A U 1 SINGLE WALL C. MATERIAL AND A U I BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A U 4 FIBERGLASS PIPE A U 7 STEEL-WI UNATING A U 1000YTM.�METHANOL COMPATIBLE W/FRP CORROSION A U 5 ALUMINUM A U 6 CONCRETE PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 1 MEGUNGL LNE LEN( ❑2 LNE TIGmIlE59 E]3 CWII0XJS mrPAsmuL ❑4 UACiR �I� ❑5 PI#i ❑ 99 M.H.B. LEAK DETECTION ❑ DE ao# msmi MwwcRmo VrEg7TANK LEAK DETECTION VISUAL CHECK ❑ 2 RECCONCILIATIONORV ❑ 3 VADOZEMONITORING ❑ 4GAUL NGC TANK ❑ 5 MONITORINOUND G ❑a TESTNGTANK MONITORING INTERSTITIAL ❑ 9 SIR ❑ 9 TREK GAUGINGAL ❑10 MONTHLTESTINGY TANK ❑ 95 UNKNOWN ❑99 OTHER VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED ? YES a NO❑ I.ESTIMATED DATE LAST USED(MO/DAY/YR) SUBSTANCE REMAINING GALLONS INERT MATERIAL AL7 THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY.AND TO THE BEST OF MY KNOWLEDDGEEIS TRUE AND CORRECT TANK OWNER'S NAME (PAK=&SIGNATURM LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW TANK# COUNTY# JURISDICTION# FACILITY# STATE I.D.# m uT�1�J PERMIT APPROVED BYIDATE PERMIT IXPIR D PERMIT NUMBER �1 THIS FORM MU SHOULD BE ACCOIMPANIED BY AI PLOT PLAN. FILE THIS ORM WITH THE CURRENT OCAL AGE AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS THIS FORM FORMS (6.95)