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• , � � wiiWwCCi STATE OF CALIFORNIA ti STATE WATER RESOURCES CONTROL BOARD o 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 4SITT ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ® 8 TANK REMOVED D DBA OR FACILITY NAME WHERE TANK IS INSTALLED: I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IFU KNOWN A OWNER'S TANK LD.N B. MANUFACTURED BY: `/ _y C. DATE INSTALLED(MOIDAYNEAR) _ D. TANK CAPACITY IN GALLONS: II.TANKx CONTENTS IFA-1 IS MARKED,COMPLETE ITEM C. l A 1 yl 1 MOTOR VEHICLE FUEL ❑ q OIL 8. C - la REGULAR UNEADED ❑ 3 DIESEL ❑ 8 AVIATION GAS 7❑-' 2 PETROLEUM ❑ BO EMPTY PpODUUI 1b PflEMIUM UNLEADED ❑ { GA$gH0 ❑ 7 METHANOL ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 1c MDGRAOE UNLEADED ❑ 5 JETFUEL ❑ 8 M85 ❑ 2 LEADED ❑ 99 OTHFA(DESCRIBE IN ITEM D.BELOW) D. IF(A1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A S.N III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A,B.AND C,AND ALL THAT APPLIES IN BOX D AND A. TYPE OF ❑ i 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 Wl FIBERGLASS REINFORCED PLASTIC MATERIAL 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP (Pdn Wy Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER C.INTERIOR ❑ I 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 100% METHANOL? YES_ NO- 0.EXTERIOR ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC CORROSION PROTECTION ❑ 5 CATHODIC PROTECTION91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER E.SPILL AND OVERFILL,BIO, SPILL CONTAINMENT I STALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) DROP TUBE VES_ 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 95 UNKNOWN A U 99 OTHER C. MATERIAL AND A(U)l BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A U 4 FIBERGLASS PIPE CORROSION A 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 ME" ❑2 UNE TIGH1NF56 ❑3 GIXRIMIWG WIEPSTIRIL d EIECfPGNIG DNE a 5,1UfGAUTIC W1P OETECfOB TESTING Y011TMMG I£Ax GEtE M WU}:nC ❑ 99 OTHER V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 MANUAL INVENTORY ❑ 3 LIATION MAADOZERING ❑ 4 GAUGING TANK ❑ 5 GROUND WATER ❑6 ANNUALTANK ❑ 7 MONITORING NUOUS INTERSTITIAL ❑ TESTING 8 SIR ❑ 9 WEEKLY MANUAL ❑10 MONTHLY TANK ❑ 95 UNKNOWN ❑ 99 OTHER TANK GAUGING TESTING VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PUCE) 1.ESTIMATED DtjTE LAST USEDMO/DAV/YR 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH SUBSTANCE REMAINING �`J GALLONS INERT MATERIAL? YES ❑ NO THIS FORM HAS BEEN COMPLETED UNDER PENA OF PERJURY,AND TO THE B T OF MY KNO LEDGE, IS TRU AND COR CT TANK OVdRER'S NAME / 1 I (PRINTED a SIGNATURE) �/A J/ -�/1 I 2u�^ �J�..� LOCAL AGENCY USE ONLY/L at !IM- THE ISITAATE I.D.NUMBER IS COMPOSED OF THE FO IR NI MBERS BEI O(WN l x G COUNTY N JURISDICTION N FACILITY N TANK N STATE I.D:# m = � PERMIT NUMBER PERMIT APPROVED BYIDATE PERMIT EXPIRATION DATE A,7(A 11 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 PLAFILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE U RGROUNO STORAGE TANK REGULATIONS FORME (6-95) 1 5 1 13r q9 I-e1J w/J