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STATE STATE OF CALIFORNIAWATER RESOURCES CONTROL BOARD • UNDERGROUND STORAGE TANK PERMIT APPLICATION-FORM B oy ;• o COMPLETE A SEPARATEFOR ' MARK ONLY ❑ M FOR EACH TANK SYSTEM, ONE REM I NEW PERMIT ❑ 2 INTERIM PERMIT ❑ 3 RENEWAL PERMIT ❑ 4 AMENDED PERMIT ❑ 5 CHANGE OF INFORMATION DBA OR FACILITY NAME ❑ 6 TEMPORARY TANK CLOSURE I. TANK D7 PERMANENTLY CLOSED WHERE TANK IS INSTALLED; a TANK R ONSITE ESCRIPTION EMOVED A OWNER'S TANK I.D.# COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN C. DATE INSTALLED(MO/DAY/YEARI / B. MANUFACTURED BY: II.TANK CONTENTS / D. TANK CAP 1 MOTOR VEgCIry IN GALLONS. A-1 IS MARKED,COMPLETE ITEM C. � HICLE FIF A FUEL ❑ 2 PETROLEUM ❑ 0 OIL B. ❑ 80 EMPTYPRODUCT C ❑ 1b PREMIUM UNLEADED UNLEADED 3 DIESEL ❑ 3 CHEMICAL PRODUCT s-� ❑ 6 AVIATION GAS ❑ 85 UNKNOWN ❑ is MIDGRADE U 4 GASAHOL ❑ 7 METHANOL D. IF(A.1)IS NOT MARKED, ENTER NAME OFSU13STANCE STORED ❑ 2 WASTE UNLEADED ❑ 5 JET FVEL ❑ ❑ 2 LEAOEO 8 M85 III. TANK CONSTRUCTION ❑ 99 OTHER(DESCgiBE IN ITEM D.BELOW) MARK ONE ITEM ONLY IN BOXES C.A S.#: A. TYPE OF ❑ A B,AND C,AND ALL THAT APPLIES IN BOX D AND E 1 DOUBLE WALL ❑ 3 SINGLE WALL H EXTERIOR LINER WIT SYSTEM �2 SINGLE WALL ❑ 0 SINGLE W ❑ ER SYSTEM ALL IN A VAULT 5 INTERNAL BLADDER 1195 UNKNOWN B. TANK �1 BARE STEEL ❑ 99 OTHER MATERIAL ❑ 5 CONCRETE ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ q STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC (Primary Tank) ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN 8 100% METHANOL COMPATIBLE W/FRP C.INTERIOR ❑ 1 RUBBER UNEP ❑ 99 OTHER LINING OR ❑ 2 ALKYD LINING E] 3 EPDXY LINING ❑ 5 GLASS LINING T��/// ❑ 4 PHENOLIC LINING COATING 6 UNLINED El 95 UNKNOWN IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES ❑ 99 OTHER D.EXTERIOR VES— NO-X CORROSION ❑ I POLYETHYLENE WRAP ❑ 2 COATING ED VINYL WRAP El FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ��g7 NONE SPBL COMI11_A I ED 1 1 El 95 UNKNOWN ED 99 OTHER E.SPILL AND OVERFILL,lCC. pip TUBE AINM 1 NC ) OVEgFlLL PRE NENN710 EQUIPMENT INSTALLED(YEAR) STRIKER PLATE VES IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND,BOTH IF APPLICABLE DISPENSER CONTAINMENT YES NO A. SYSTEM TYPE AnI SUCTION A U 2 PRESSURE A U 3 GRAVITY q U 4 FLEXIBLE PIPING B. CONSTRUCTION A 1 SINGLE WALL A U 2 DOUBLE WALL A U 99 OTHER A U 3 UNED TRENCH A U 95 UNKNOWN A U C. MATERIAL AND A U I BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL 99 OTHER CHLORIDE(PVC)A U CORROSION A U 5 ALUMINUM A U a CNCRETE 4 FIBERGLASS PIPE PROTECTION A U T STEEL COATING A U U 9 GALVANZED STEEL A U 70 CATHODIC PROTECTION A U 955 8 100% METHANOL COMPATIBLE W/FRP ON D. LEAK DETECTION ❑1 cHm � A U 99 OTHER_ �A'I 2 mm ss ❑s sRBgslmAl ❑4 BEcmoNO KNOWN N 5 AmoMAnc PUMP IEuc BSIEcroq ❑ V.TANK LEAK DETECTION sRuroowN ❑ 99 o H6q OZE I VISUAL CHECK X 2 ECO CILATIONMANUALORY ❑ 3 MONITORING ❑ 4 AUTOMATIC TANK 5GAUGING GROUND WATER 6 ANNUAL TANK ❑ 7 CONTNUOUSIM73iSPTIAL ❑ ! SIR 9 WEEKLY MANUAL ❑ 10 ONTHLY TANK MONITORING MONITORING ❑ TANK GAUGING ❑ 95 UNKNOWN TESTING TESTING ❑ 69 OTHER VL TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE I.ESTiMATF=ATE LA USED( AY/YR) 2.ESTIMATED OUANn OF SUBSTANCE REMAINING `�D�GALLONS 3'WAS INERT MATERIAL 7TH YES NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND❑CORRECT TANK OWNER'S NAME (PRINTED B 61GNATUgR DATE LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW STATE I.Dl COUNTY# JURISDICTION# FACILITY# /y TANK# PERMIT NUMBER qz PERMIT APPROVED BV/DATE --��WW '�--`--�- T 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 FORMS (695)SHOULD BE ACCOMPANIED BY A PLOT PLVLE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE GROUND STORAGE TANK REGULATIONS