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STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION -FORM B 1 COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED ON SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT �6 TEMPORAflY TANK CLOSURE ❑ 8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: `? 4A Ic I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A OWNER'S TANK I.D.# B. MANUFACTURED BY: ytlyt r�C.e. C. DATE INSTALLED(MO/DAWYEAR) D. TANK CAPACITY IN GALLONS: If.TANK CONTENTS IFA-1 IS MARKED,COMPLETE ITEM C. A. ❑ t MOTOR VEHICLE FUEL 4 OIL B. C, ❑ 1a REGULAR UNLEADED ❑ 3 DIESEL ❑ 6 AVIATION GAS ❑ 2 PETROLEUM ❑ 80 EMPTY ❑ 1 PRODUCT ❑ ib PREMIUM UNLEADED ❑ 4 GASAHOL ❑ 7 METHANOL ❑ 1C MIDGRADE UNLEADED ❑ 5 JET FUEL ❑ 8 M85 ❑ 3 CHEMICALPRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED ❑ 99 OTHER(DESCRIBEIN ITEM D.BELOW) D. IF(AA)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 ❑ I DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 5 INTERNAL BLADDER SYSTEM ❑ 95 UNKNOWN SYSTEM Imo/2' SINGLE WALL ❑ 4 SINGLE WALL IN A VAULT ❑ 99 OTHER B. TANK .LY 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBI n 4 STEEL CLAD W'FIBERG2.'.',REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLWINY_ CHLORIDE ❑ 7 ALUMINUM ❑ 8 100116 METHANOL COMPATIBLE W/FRP ` (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER C.INTERIOR ❑ I RUBBER LINED ❑ 2 ALI;YO LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING LINING OR ❑ 5 GLASS LINING ❑ 6 Ur'_INED ❑ 95 UNKNOW//N ❑ 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 10P„ METHANOL? YES_ NOLO�� 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 SPILL CONTAINM,ENTINSTALLED fAR) VERFILI PREVENTION EQUIPMENT INSTALLED(NEAR) ' E.SPILL AND OVERFILL,etc. DROP TUBE YES_ NO STRIKER PLATE YES_ N0= DISPENSER COMAINMENT YES_ NO IV.PIPING INFORMATION CRCLE A IF ABOVE GROUND OR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U1 5 .TION A U 2 PRESSURE A U GRAVITY A U 4 FLEXIBLE'PIPING A U 99 OTHER B. CONSTRUCTION A U 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 7 STEEL W/COATING A U B 100% METHANOL COMPATIBLE W/FRP PROTECTION AU 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTIDN r 1 MECHANICAL ME LEAK E::]2 LINE TGKINESS ❑3 WNTINUWS WrERSPnAL O 1 ELIMMIC ONE D 5 AUIOMATC PUMP 9 OTHER I)ETECTOR TESTNG MONITMM LEAK DETECTOR SHUTDOWN V.TANK LEAK D rECTION ❑ 1 VISUAL HECK ❑ 2 RMANUAL ECONCILIATION ❑ 3 VADOZE MONITORING ❑ 4 GAUGING AUTOMATIC TANK ❑5 GROUND MON TORINGTER ❑ 6 ANNUALTES-TING ❑ 7 MON TOFING INTERSTITIAL ❑ 8 SIR ❑ 9 WEEKLY K LY MANUAL ❑10 MOTESTINGHL TANK ❑ 95 UNKNOWN p.99 OTHER VI.TANK CL JSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) 1.ESTIMATE DATE LAST USED(MO/DAWYR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES ❑ NO❑ SUBSTANCE REMAINING GALLONS INERT MATERIAL? TH/S FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT DATE TANK OWNER'S NAME (PRIMED 6 SIGNATURE) LOCAy AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW IC°u L J 1 COUNTY# JURISDICTION If FACILITY# TANK# STATE LD:# N t M7= r PErPERMIT APPROVED BVIDATE PERMIT EXPIRATION DATE .AMIT NUMBER LTHIS ORM 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 PILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THERGROUND STORAGE TANK REGULATIONS M B (6-95)