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' • STATE OFCAUFORNIA • "`�op,�es STATE WATER RESOURCES CONTROL BOARD O UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B " p�i�rpl COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ❑ i NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ T PERMANENTLY C SED ONSITE ONE REM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE B TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: I. TANK DESCRIPTION COMPLETEALLITEMS- SPECIFYIFUNKNOWN A OWNER'S TANK I.D.# VA\ B. MANUFACTURED BY: y(. C. DATE INSTALLED(MOIDAYNEAR) t4kA _ D. TANK CAPACITY IN GALLONS: 8 V II.TANK CONTENTS IF A-1 IS MARKED,COMPLETE ITEM C. A. 1 MOTOR VEHICLE FUEL ❑ 4 OIL B.H 0. ❑ 1a REGUUfl UNLEADED ❑ 3 DIESEL ❑ 6 AVIATION GAS ❑ 2 PETROLEUM ❑ 80 EMPTY -11 PRODUCT ❑ 1D PREMIUM UNLEADED ❑ 4 GASAHOL ❑ T METHANOL �-1c MIDGRADE UNLEADED ❑ 5 JET FUEL ❑ B M85 ❑ 3 CHEMICALPRODUCT E] 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED ❑ 99 OTHER(DESCRIBE IN ITEM D.BELOM 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 I� 2 SINGLE WALL ❑ 4 SINGLE WALL IN A VAULT ❑ 99 OTHER B. TANK 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W1 FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ T ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP (Mmary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER C.INTERIOR ❑ 1 RUBBER UNED ❑ 2 ALKYD LINING ❑ 3 EPDXY UNING ❑ 4 PHENOLIC LINING LINING OR ❑ 5 GLASS LINING 64 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 TV'1lai 91 NONE ❑ 95 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 qQ 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION A 1 SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND AU 1 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 T STEEL W/COATING A U 8 100% METHANOL COMPATIBLE WIFRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION ' "`B H (CAL(INE UT K 2 LINE MlnM55 3 CWNIIW5 INTERSTITIAL 4 EIECM0111C NNE 5 AM01MVC NNP ❑ OEIECTOR TESTING MONTwim ❑ tUK OETI:CTOR ❑ SNUwm ❑ 99 OTHER V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK E] 2 MANUAL INVENTORY E] 3 ATION MON0ITORING ❑ 4 GAUGING IC TANK ❑5 MONITORINGGROUND TER ❑ 6 TESTING ❑ T MONITORING INTERSTITIAL ❑ 8 SIR ❑ 9 TANKGAUGINGAL E::] 10 TESTITINGV TANK 95 UNKNOWN ❑99 OTHER VI.TANK CLOSURE INFORMATION(PERMANENT CLOSUR IN-PLACE) 1.ESTIMATED DATE LAST USED(MOIDAYNR) 2.ESTIM ED QUANTITY OF 3.WAS TANK FILLED WITH SUBS NCEREMAINING GALLONS INERT MATERIAL? YES ❑ NO THIS FORM HAS BEEN COMPLETED UNDER PENA OF RJURY,ANe TO THE B ST OF MY KNOWLEDGE,IS TRUE AND COR ECT TANK OWNER'S NAME( ; I �r DATE LOCAL AGENCY USE ONLY THE STATE I.D.NU RIS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY#11 lb TANK# 7 STATE I.D.# m PERMIT NUMBER PERMIT APPROVED BYIDATE PERMIT EXPIRATION DATE THIS FORM MUSTSHOULD BE ACCOMPANIED BY AIPLOT PWFILEFORM THIS ORM WITH THE LOCAL AGENCY IMPLEMENTING THUNLESS A CURRENT FORM A HAS BEEN FILED. IWRGROUND STORAGE TANK REGULATIONS MUST BE COMPLETED FOR 5. THIS FORM FORME (&95) 1--a /f It V v Q 1�e