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STATE OF CALIFORNIA .' '; STATE WATER RESOURCES CONTROL BOARD x d� _ 8 UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B ~: _ , I COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION In 7 PERMANENTLY C 0 l ONE REM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE E] 8 TANK REMOVE DBA OR FACILITY NAME WHERE TANK IS INSTALLED: I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A. OWNER'S TANK L.D.N Uk B. MANUFACTURED BY: uk C. DATE INSTALLED(MO/DAY/YEAR) Uk D. TANK CAPACITY IN GALLONS: II,TANK CONTENTS IF A-1 IS MARKED,COMPLETE ITEM C. FXJ 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C. ❑ to REGULAR UNLEADED ❑ 3 DIESEL ❑ 6 AVIATION GAS A. ❑ 2 PETROLEUM ❑ 80 EMPTY 1 PRODUCT ❑ 1b PREMIUM UNLEADED ❑ 4 GASAHOL ❑ 7 METHANOL ❑ 1O MIDGRADE UNLEADED ❑ 5 JET FUEL ❑ 8 M85 ❑ 3 CHEMICALPRODUCT ❑ 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 A. TYPE OF ❑-I 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR UNEP E] 5 INTERNAL BLADDER SYSTEM E] 95 UNKNOWN SYSTEM II-J�-TI 2 SINGLE WALL ❑ 4 SINGLE WALL IN A VAULT ❑ 99 OTHER B. TANK L'J 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% 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 ® B UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 100Y. METHANOL? YES— NO— D.EXTERIOR ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC CORROSIONg1 NONE O 95 UNKNOWN ❑ 99 OTHER PROTECTION E:] 5 CATHODIC PROTECTON DO SPILL CONTAINMENT INSTALLEp,(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) E.SPILL AND OVERFILL,6lC. DROPTUBE YES_ NO�_ STRIKERPLATE YES_ NO� DISPENSER CONTAINMENT YES_ NO IV.PIPING INFORMATION CIRCLE AIF ABOVE GROUND OR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A Q) 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION A O 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 7 STEEL W/COATING A U a 100% METHANOL COMPATIBLE WIFRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A O 95 UNKNOWN A U 99 OTHER 1 MECHPNIGL NNE LEAK 2 UNE BGMNE55 ❑3 COMINUOUS IM TITIAL ❑d ELAn MC UNE ❑5 AMOAUTIC PUMP ❑ OTHER D. LEAK DETECTION ❑ OETECTON ❑ MSNG MOMTOMNG PEAK OETEmOR SHVi00WN V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 RMANUAL ECONCILIIATIONORY E] 3 MONITORING ❑ 4 GAUGNGVADOZEAUTOMATIC TANK ❑5 MONITORINGGROUND TER ❑ 5 TTEESTINGAL TANK ❑ 7 MON INUOU INTERSTITIAL ❑ B SIR ❑ 9 WEEK LY MANUAL ❑10 MO THLY TANK ® 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) 1.ESTMATED DATE LAST USED(MO/DAYR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES ❑ NOP Uk SUBSTANCE REMAINING In GALLONS INERT MATERIAL? �( THIS FORM HAS BEEN COMPLE E NDE P I.7y OF KF JURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT DATE TANK OWNER'S NAME 2/18/97 (PRIMED d SIGNATOR LOCAL AGENCY USE ONLY TH TATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY# 4`I� TANK# a STATE I.Dl m = - 0 ;y0] PERMIT NUMBER PERMIT APPROVED BYIDATE PERMIT EXPIRATION DATE THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLI ON-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. FOWB�LLC MUST BE COMPLETED FOR INSTALLATIONS.THIS FORM SHOULD BE ACCOMPANIED BY A PLOT FWILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTNG TH GROUND STORAGE TANK REGULATIONS (1I FORM B (6-95) (11