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• • - STATE OF CALIFORNIA • STATE WATER RESOURCES CONTROL BOARD • '• .'c �o UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B ma I . Q COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY NEW PERMIT ❑ 3 RENEWAL PERMIT ><5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED O ONE REM 2 INTERIM PERMIT O 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: S I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A OWNER'S TANK I.D.# 3 B. MANUFACTURED BY: l7(/L5GO C. DATE INSTALLED(MODAYNEAR) OG7 [ I R- D. TANK CAPACITY IN GALLONS: PVn II.TANK CONTENTS IFA-1 IS MARKED,COMPLETE, ITEM C. LN A ,®-1 MOTOR VEHICLE FUEL ❑ d OIL B. C. 1a REGULAR UNLEADED �3 DIESEL ❑ 6 AVIATION GAS ❑ 2 PETROLEUM ❑ 80 EMPTY 1 PRODUCT ❑ lb PREMIUM UNLEADED O 4 GASAHOL ❑ 7 METHANOL E:] 3 CHEMICAL PRODUCT O 95 UNKNOWN ❑ 2 WASTE E::] 1C MIDGRADE UNLEADED ❑ 5 JET FUEL ❑ B M85 E] 2 LEADED ❑ 99 OTHER(DESCRIBE IN TEM D.BELOW) D. IF(A.1)IS NOT MARKED, ENTER NAME OFSUBSTANCE STORED C.A.S.#: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A,S,AND C,AND ALL THAT APPLIES IN BOX D AND E A. TYPE OF ISI I DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER O 5 INTERNAL BLADDER SYSTEM ❑ 95 UNKNOWN SYSTEM ❑ 2 SINGLE WALL ❑ 4 SINGLE WALL IN A VAULT ❑ 99 OTHER B. TANK ❑ 1 BARE STEEL O 2 STAINLESS STEEL ❑ 3 FIBERGLASS t , 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE Ej 7 ALUMINUM 08 100% METHANOL COMPATIBLE W/FRP (P"—ry Tank) ❑ 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 �6 UNLINED ❑`955UUNKNOWN E] 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 10D% METHANOL? VESTS NO_ D.EXTERIORF11 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP �4 FIBERGLASS REINFORCED PLASTIC CORROSION PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE ❑ 95 UNKNOWN O 99 OTHER E.SPILL AND OVERFILL,MC. SPILL CONTAINME T I STALLED(YEAR) NSTAL OVERFILL PREVENTION EQUIPMENT ILED(YEAR) DROP TUBE YES NO STRIKER PLATE VES NO_ DISPENSER CONTAINMENT VES NO IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION A 2 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL A 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 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 1 uEawncu ME t1AK ❑2 LFIE TK,IrtxEss 3 caxnxuous IxIERSTmu ❑d FIECniDMC UNE 5 AlIf01MTG PUMP DETECTOR TEa M YONTORNG LFAx DEIECIOR SHUTDOWN ❑ 99 OTHER V.TANK LEAK DETECTION INVENT❑ 1 VISUAL CHECK E] 2 RECONCILIATION MONITORING E:] 3 MONIITORING OZE 4 AUTOMATGAUGINGIC TANK E::] 5 MONITORINGTER ❑ e TESTTIINGTANK ANUAL 7 MOCONTINUOUS TORNG INTERSTITIAL ❑ 8 SIR ❑ 9 TANEK GAUGINGAL ❑10 MONTHLY TANK ❑ 95 UNKNOWN ❑99 OTHER TESNG VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PUCE) Aj, 1.ESTIMATED DATE LAST USED(MO/DAY/YR) /Y1 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH vec SUBSTANCE REMAINING GALLONS INERT MATERIAL 7 THIS FORM HAS BEEN C M ETD DER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT TANK OWNER'S tAME DATE (PRINTED A SIGNA E) 11- wL ( p e, LOCAL AGENCY US L TH TATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY#Q9 '� TANK#OD,3 STATE LD:# m L D (� PERMIT NUMBER PERMIT APPROVED BYIDATE PERMIT EXPIRATION DATE fD 471 THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPUCAT10N-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. FORM C MUST BE COMPLETED FOR INSTA,I AlfONAINSTAL .THIS FORM SHOULD BE ACCOMPANIED BY A PLOT PILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE orGROUND STORAGE TANK REGULATIONS FORMS (6-95)