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• • STATE OF CALIFORNIA �e �% STATE WATER RESOURCES CONTROL BOARD a��, .o a UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B I COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ PERMANENTLY CLOSED ON SITE ONE REM F72 INTERIM PERMIT ❑ 4 AMENDED PERMIT F76 TEMPORARY TANK CLOSURE V8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: I. TANK DESCRIPTION COMPLETE ALL ITEMS– SPECIFY IF UNKNOWN A OWNER'S TANK I.D.# 00 /a I B. MANUFACTURED BY: C. DATE INSTALLED(MOIDAYIYEAR) D. TANK CAPACITY IN GALLONS: Q II.TANK CONTENTS IF A-1 IS MARKED,COMPLETE ITEM C. A ❑ 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C. Ela REGULAR UNLEADED ❑ 3 DIESEL 6 AVIATION GAS F-] 2 PETROLEUM ❑ 80 EMPTY ❑ 1 PRODUCT E_] tb PREMIUM UNLEADED ❑ 4 GASAHOL ❑ 7 METHANOL ❑ lc MIDGRADE UNLEADED ❑ 5 JET FUEL ❑ 8 M85 ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED ❑ 99 OTHER(DESCRIBE IN REM D.BELOW) 0. IF(A.1)IS NOT MARKED, ENTER NAME OFSUBSTANCE 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 LINER ❑ 5 INTERNAL BLADDER SYSTEM ❑ 95 UNKNOWN SYSTEMSINGLE WALL ❑ 4 SINGLE WALL IN A VAULT ❑ 99 OTHER B. TANK EYr, BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP (Primary 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 rig UNLINEDff4--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 ❑ 91 NONE 5 UNKNOWN ❑ 99 OTHER E.SPILL AND OVERFILL,BIC. 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® 2 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION Ao 1 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 W/COATING A U 8 100% METHANOL COMPATIBLE WIFRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A® 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION [:]' MECHANICAL LINE LEAK [:]2 UNE MKINESS 3 COWINUWS IWERCiITIAL ❑4 ELECIRMIC UNE �5 AUIOMAnC PUMP ❑ B9 OTHER OE1ECi0R TESTND TESTING MOORING UFAK DETECTOR SHU"FMM V.TANK LEAK DETECTION ❑ I VISUAL 7 CONTINUOUS INTERSTITIAL ❑ 2 MANUAL RECONCILIATIONMONITORING❑ 9 MONIWEETORING ❑ 4 AUTOMATIC 0 MON GAUGING TANKK ❑ 55�jGROUND dUNKNOWN GWATER ❑ 99 OTHER TANK ❑ MONITORING ❑ 8 SIR TESTING ❑ TANKGAUGING ❑ TESTING `w ❑ VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) 1.ESTI ATED D TE LAST UBED(MO/DAVlVR) 2.ESTIMATED QUANTITY OF 9 3.WAS TANK MATERIAL WITH YES ❑ NO SUBSTANCE REMAINING f_�U GALLONS INERT MATERIAL 7 THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT TANK OWNER'S NAME DATE (PRINTED 6 SIGNATURE) LOCAL AGENCY USE ONLY 1 THE STATE I.D.NU ER IS COMPOSED OF THE FOUR UMBERS BELOW COUNTY# JURISDICTION# FACILITY# TANK# STATE I.D.# m 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 PLOT PILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE�RGROUND STORAGE TANK REGULATIONS FORM 8 (6.95)