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STATE OF CALIFOPNIA °"�.�..° STATE WATER RESOURCES CONTROL BOARD �� UNDERGROUND STORAGE TANK PERMIT APPLICATION-FORM B =� 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 ❑ 5 TEMPORARY TANK CLOSURE t2f' TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: c ' I. TANK DESCRIPTION COMPLETE ALL ITEMS— SPECIFY IF UNKNOWN A OWNER'S TANK I.D.♦ B. MANUFACTURED BY: C. DATE INSTALLED(MO/DAYNEAR) .� D. TANK CAPACITY IN GALLONS: II.TANK CONTENTS IFA-1 IS MARKED.COMPLETE ITEM C. A. [�ZL 1 MOTOR VEHICLE FUEL ❑ 4 OILB. 0. 1e REGULAR UNLEADED 3 DIESEL L_] 6 AVIATION GAS ❑ 2 PETROLEUM ❑ 80 EMPTY �. i PRODUCT ❑ 1D PREMIUM UNLEADED 4 GASAHOL ❑ 7 METHANOL ❑ 9 CHEMICAL PRODUCT ❑ 85 UNKNOWN ❑ 2 WASTE ❑ le MIDGRADE UNLEADED ❑ 5 JET FUEL ❑ 8 M85 2 LEADED ❑ 99 OTHER(DESCRIBE IN ITEM D.BELOW) D. IF(Al)IS NOT MARKED. ENTER NAME OF SUBSTAGE STORED C.A.S.R: 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 B. TANK ❑ 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL F-� 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE 7 ALUMINUM ❑ B 100% METHANOL COMPATIBLE W/FRP (PdmNy 7590 ❑ 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 ❑ e 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 ❑ 81 NONE ❑95 UNKNOWN ❑ 99 OTHER E.SPILL AND OVERFILL,etc. 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 2 DOUBLE WALL A U 3 LINED TRENCH A U 85 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 a 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 U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION ❑l uEcxuacu UNE D.Uf 2 trE 1MmrBss ❑3 OamNu NTDmmAL Pure ❑4 ELEcmoxlc UN gE s AVroMlnc OEDCf011 1E41Vl0 MDNf03N0 DAX!DEIEC9N100WN ❑99 OTHER V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 RECONCILIATIONORY ❑ 3 MONITORING ZE ❑ 4 GAUGING TANK ❑5 MON TORINGTER ❑B TAENSTNGTANK ❑ 7 MONITORING NUOUS INTERSTITIAL ❑ B SIR ❑ 9 EKL MANUAL ❑10 M TESTING TANK ❑ 95 UNKNOWN ❑99 OTHER Vi.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PUCE) 1.ESTIMATED DATE LAST USED(MOIDAYNR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH VES ❑ NO ❑ SUBSTAGE REMAINING GALLONS INERTMATERIALT THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUEAND CORRECT TANK OWNER'S NAME DATE (PRINTED 6 SIGNAT RE) LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY M JURISDICTION M FACILITY N TANK* STATE I.Dl m = I I I I = AZI(q�?110121- PERMIT NUMBER PERMIT APPROVED BYIDATE PERMIT EXPIRATION DATE 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 SHOULD BE ACCOMPANIED BY A PLN. RLE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING T}JEUNDERGROUND STORAGE TANK REGULATIONS FORM 8 (6-95)