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4 STATE OF CALIFORNIA •° a V A j`s STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B i , COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ❑ 1 TPERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ON SITE ONE ITEM ❑ 2 INTERIM NINTE RfM PERMIT ❑ 4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE 8 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.# B. MANUFACTURED BY: C. DATE INSTALLED(MOIDAYNEAR) u/ D. TANK CAPACITY IN GALLONS: II.TANK CONTENTS IF A-1 IS MARKED,COMPLETE ITEM C. qX 1 MOTOR VEHICLE FUEL ❑ 4 OIL R. C' L71"' 1a REGULAR UNLEADED ❑ 3 DIESEL 1:J6 AVIATION GAS Cl2 PETROLEUM 80 EMPTY 1 PRODUCT ❑ 1b PREMIUM UNLEADED a 4 GASAHOL ❑ 7 METHANOL �'^ ❑ 1c MIDGRADE UNLEADED ❑ 5 JET FUEL ❑ 8 M85 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE 2 LEADED 99 OTHER(DESCRIBE IN ITEM D.BELOW) 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 p -YPE OF F—] 1 DOUBLE WALL [--] 3 SINGLE WALL WITH EXTERIOR LINER 1-15 INTERNAL BLADDER SYSTEM 7] 95 UNKNOWN _NI J><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 ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE WIFRP (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER C.INTERIOR Ell RUBBER LINED ❑ 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°/a METHANOL? YES_ NO_x 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 EtC, SPILL CONTAINMENT INSTALLED,(Y R) OVERFILL PREVENTTC OUIPMENT INSTALLED(YEAR) IV 17 DROP TUBE YES NO TRIKER PLATE YES NO DISPENSER CONTAINMENT YES NO W.PIPING INFORMATION CIRCLE A IF ABOVEGROUND 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 U 799 OTHER B. CONSTRUCTION A U 1 SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A 4)95 UNKNOWN A U 99 OTHER C. MATERIAL AND A&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 WICOATING A U 8 100% METHANOL COMPATIBLE WIFRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION 4095 UNKNOWN A U 99 OTHER D. LEAK DETECTION1 MECHANICAL LINE LEAK I— 2 LINE TFGHTNESS 3 CONTINUOUS INTERSTITIAL ❑4 ELECTRONIC LINE �5 AUTOMATIC PUMP 99 OTHER �L�—. DETECTCR L� TESTING MONITORING LEAK DETECTOR SHUTDOWN V.TANK LEAK DETECTION VACOZE F71 VISUAL CHECK ❑ 2 RECONCILIATIONOAY ❑ 3 MON17ORING 4 GAUG NG IC TANK ❑r5 MROUND ON TORINGTER ❑ 6 TESTING ❑ 7 MONITORCONTINUOUS INTERSTITIAL ❑ 8 SIR ❑ 9 TANK WEEKLY MAINUAL ❑ 10 T 0 STING TANK I� I 955 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) Y� 1.ESTIMATED DATE LAST USED(MOIDAYIYR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES F7NO SUBSTANCE REMAINING GALLDNS 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 8 SIGNATUREI LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW STATE L.D:# COUNTY# JURISDICTION# FACILITY# �j } TANK# d/ PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE oy (^ x Y/ f THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPU_!;?TION-FORMA,UNLESS A CURRENT FORMA HAS BEEN FILED. JdM C MUST BE COMPLETED FOR INSTALLATIONS. THIS; SHOULD BE ACCOMPANIED BY A PLOT, TLE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING TI�`' AGROUND STORAGE TANK REGULATIONS r q FORM B (6-95) s :`�''i !