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• STATE OF CALIFORNIA • w''ce '<" 0 STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B en _ 1 COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. ❑ ERMIT �Jy` CHANGE OF INFORMATION ❑ T PERMANENTLY CLOSED ON SITE MARK ONLY r-11 NEW PERMIT 3 RENEWAL P >! _ 8 TANK REMOVED I� ONE ITEM El2 INTERIM PERMIT ❑ 4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE ❑ DBA OR FACILITY NAME WHERE TANK IS INSTALLED: ,;L I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A OWNER'S TANK I.D.4 yI B. MANUFACTURED BY: C. DATE INSTALLED(MO/DAY/YEAR) (�{iy�iL, D. TANK CAPACITY IN GALLONS: II.TANK CONTENTS IFA-1 IS MARKED,COMPLETE ITEM C. 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C. Ella REGUPREMIUM UNLEADED ❑ 3 DIESEL ❑ B AVIATION GAS A 2 PETROLEUM BO EMPTY 1 PRODUCT ❑ 1b PREMIUM UNLEADED ❑ 4 JET FUEL ❑ T METHANOL ❑ � 1e MIOGRADE UNLEADED ❑ 5 JET FUEL ❑ B M85 ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE 2S,2 LEADED ❑ 99 OTHER(DESCRIBE IN MD.BELOW) 0. IF(A1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A S.K: 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 E:15 INTERNAL BLADDER SYSTEM EJ 95 UNKNOWN SYSTEM ❑ 4 SINGLE WALL IN A VAULT ❑ 99 OTHER 2 SINGLE WALL 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B. TANK MATERIAL 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100°b 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 95 UNKNOWN ❑ 99 OTHER �Q 6 UNLINED ❑ COATING IS LINING MATERIAL COMPATIB/E'�WITH`100°6 METHANOL? YES_ NO_�< D.EXTERIOR ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC CORROSION 91 NONE 95 UNKNOWN ❑ 99 OTHER PROTECTION ❑ s cATHoolc PROTECTION ❑ SPILL CONTAINMENTINSTAILE (YEAR) OVERFILL PREVENTI N EQUIPMENT INSTALLED(YEAR) E.SPILL AND OVERFILL,BIC. DROP TUBE VES__ NO NO DISPENSER CONTAINMENT VES_ NO STRIKER PLATE YES_ 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 A099 OTHER S. 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 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 T STIES W/COATING A U B 100% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A 5 UNKNOWN A U 99 OTHER— u- 1 MECWWICUL UNE tFAK 2 LINE TK WMW ❑3 CCNBNUWS INTERSTITIAL ❑4 ELECIRONN:NNE ❑5 AUTOLNTIC PUMP 99 OTHER D. LEAK DETECTION ❑ CETECTCR ❑ TESTING WWORNG LEAK mmc1GR mules I V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 RECONCILIATIONINVENTORY ❑ 3 MONIITORING ❑ 4 GAUGNG AUTOMATIC TANK ❑55 MONTORINGGROUND TER ❑ 6 TESTINGTANK ❑ Z MONITORING G INTERSTITIAL ❑ 8 SIR ❑ 9 TANK GAUGINGAL ❑10 MONTHLY TANK IJ�g5 UNKNOWN ❑99 OTHER VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PUCE) 1.ESTIMATED DATE LAST USED(MO/DAYN 1 2.ESTIMATED OUANTITY OF 3,WAS TANK FILLED WITH YES ❑ NO ❑ SUBSTANCE REMAINING GALLONS INERT MATERIAL? THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MV KNOWLEDGE, IS TRUE AND CORRECT DATE TANK OWNER'S NAME (PRINTE0451GNATURE) LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW O COUNTY If JURISDICTION If FACILITY# TANK# STATE I.D.# m h D r 10 11 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 P LE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING TH RGROUNDSTORAGE TANK FORM B (6-95) 5