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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 ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION L:1 7 PERMANENTLY CLOSED ON SITE ONE REM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT r76 TEMPORARY TANK CLOSURE B TANK REMOVED /C DBA OR FACILITY NAME WHERE TANK IS INSTALLED: L L I. TANK DESCRIPTION COMPLETE ALL ITEMS— SPECIFY IF UNKNOWN A OWNER'S TANK I.D.• �)) B. MANUFACTURED Sr. C. DATE INSTALLED(MOIDAYNEAR) ),-,r " -,, 0 D. TANK CAPACITY IN GALLONS: Ii.TANK CONTENTS IF A•1 IS MARKED,COMPLETE ITEM C. to REGULAR UNLEADED ❑ 3 DIESEL ❑ 6 AVIATION GAS A 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. 0. ❑ 1b PREMIUM UNLEADED ❑ 4 GASAHOL ❑ 7 METHANOL ❑ 2 PETROLEUM ❑ BO EMPTY � 1 PRODUCT 1c MIDGNADE UNLFADED5 JET FUEL ❑ B M85 ❑ 3 CHEMICALPRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE g..2 LEADED L_j 99 OTHER(DESCRIBE IN ITEM D.BELOW) D. IF(A1)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 UNER ED INTERNAL BLADDER SYSTEM E:195 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 ❑ 5 CONCRETE ❑ 8 POLYVINYL CHLORIDE E] 7 ALUMINUM ❑ B 100% METHANOL COMPATIBLE W/FRP (PrIIllery T8nk) 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER C.INTERIOR ❑ 1 RUBBER UNED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING LINING OR ❑ 5 GLASS LINING ❑ 6 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH IDD% METHANOL? YES_ NO— D.EXTERIOR ❑ I POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC CORROSION95 UNKNOWN 99 OTHER PROTECTION ❑ 5 CATHODIC PROTECTION F791 NONE ❑ SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) E.SPILL AND OVERFILL,Bt0- 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 I SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 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 WI COATING A U B 100% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER 1 MECN QL LINE UIXE]2 Mi !E MNTNEM 3 UCUBNTF1191RIAL I 4 ELECIRDNIC UNE 5 MITO RC PUMP 99 OTHER D. LEAK DETECTION ❑ DMUM ❑ TESTmG ❑ C MON1amNa ❑ LEAN oETEOTaB ❑ 9UTWWN V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 RECONCILIATIONORY ❑ 3 VADOZE ❑ 4 GAUGING IC TANK ❑ 5 MONITORINGROUND G ❑8 SN,TUINGTANK ❑ 7 CONTINUS MONITORU INTERSTITIAL B SIR ❑ 9 WEETANKLY MANUAL ❑10 MOTESTINGHLY TANK [:j95 UNKNOWN ❑99 OTHER VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE M-PLACE) 1.ESTIMATED DATE LAST USED(MOIDAYNR) 2 ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES ❑ NO❑ SUBSTANCE REMAINING GALLONS INERTMATERIAL7 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 (PRINTED 6 SIGNATURE) LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION M FACILITY# TANK# STATE I.D.# m �r� 2 r PERMIT NUMBER PERMIT APPROVED BWDATE 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 PLO16N. FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING TF E[_IINDERGROUND STORAGE TANK REGULATIONS FORMS (6.95)