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40 STATE OF CALIFORNIA e •°pO „'°°^ STATE WATER RESOURCES CONTROL BOARD " UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM B "� m COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. 1 MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOS D ON SITE ONE REM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED ncl DBA OR FACILITY NAME WHERE TANK IS INSTALLED: l � A. I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A OWNER'S TANK I.D.# S. MANUFACTURED BY: C. DATE INSTALLED(MO/DAYNEAR) D. TANK CAPACITY IN GALLONS: / II.TANK ��CONTENTS IFA-1 IS MARKED,COMPLETE ITEM C. A "MOTOR VEHICLE FUEL ❑ 4 OIL B. rrrr----�� C. ❑ to REGULAR UNLEADED 3 DIESEL ❑ 6 AVIATIONGAS 2 PETROLEUM ❑ 80 EMPTY 1 PRODUCT ❑ 1G PREMIUM UNLEADED 4 GASAHOL ❑ 7 METHANOL ❑ 1c MIDGRADE UNLEADED ❑ 5 JETFUEL ❑ 8 M85 ❑ 3 CHEMICALPRODUCT ❑ 95 UNKNOWN Ll 2 WASTE ❑ 2 LEADED ❑ 99 OTHER(DESCRIBE IN ITEM D.BELOYD D. IF(A.1)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 LINER ❑ 5 INTERNAL BLADDER SYSTEM ❑ 95 UNKNOWN SYSTEM 2 SINGLE WALL ❑ 4 SINGLE WALL IN A VAULT ❑ 99 OTHER B. TANK � 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 UNED /I❑ 2 ALKYD LINING ❑ 3 EPDXY LINING E:] 4 PHENOLIC LINING LINING OR ❑ 5 GLASS UNING �h�L 6 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 ❑ 91 NONE 95 UNKNOWN ❑ 99 OTHER E.SPILL AND OVERFILL,BLC. 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 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION A SINGLE WALL A U 2 DOUBLE WALL A U 3 UNED 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 W/COATING A U 8 100% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION 5 UNKNOWN A U 99 OTHER D. LEAK DETECTION 01 ME=Ck UNE IFA?( ❑2 UNE TIGHTNESS ❑3 CONTIW WS INTERSTRW 4 ELECTONIC UNE 5 AWOW"IVMP CETECfOq TESTING MOMTORING LTAK OEiECTOR ❑ SNUTCONN ❑ 99 OTHER V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 L MANUALRECONCINVENTORY ❑ 3 LIATIONMONOITZE ORING E:] 4 AUTOMAGAUGINC TANK ❑5 MON ND WATER ❑ 6 ANNUATESTINGTANK ❑ 7 MON TORING INTERSTITIAL ❑ 8 SIR ❑ 9 T E K GAUGINGAL ❑10 TES NGY TANK ❑ 95 UNKNOWN ❑99 OTHER VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) 1.ESTIMATED DATE LASI USED MO/DAYNA) 2.ESTIMATED QUANTITY OF3.WAS TANK FILLED WITH 'e SUBSTANCE REMAINING_ � GALLONS INERT MATERIAL? YES ❑ NO THIS FORM HAS BE N COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND COR ECT TANK OWNER'S NAME DATE (PRNTED B SIGNATURE) LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY# TANK# fi - II STATE LDSI �-� PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE THIS THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLIICN•FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. F MUST BE COMPLETED FOR INSTALLATIONS. THIS FORM FORMS (695) SHOULD BE ACCOMPANIED BY A PU ILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THEIW GROUND STORAGE TANK REGULATIONS