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STATE OF CALIFORNIASTATE WATER RESOURCES CONTROL BOARD • UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM B COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. •� ` ' I o 0 MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ c, 'a ONE ITEM ❑ 2 INTERIM PERMIT ❑ 5 CHANGE OF INFORMATION n 7 PERMANENTLY CLOS 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE II'�_,�-''/` SITE 6 TANK REMOVED .t DBA OR FACILITY NAME WHERE TANK IS INSTALLED: V I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A OWNER'S TANK I.D.p / B. MANUFACTURED BY. C. DATE INSTALLED(MO/DAV/YEAR) TANK CAPACITY IN GALLONS: II.TANK CONTENTS IFA-11SMARKEDCOMPLETEITEMC. A. LQ 1 MOTOR VEHICLE FUEL ❑ 4 OIL B C ❑ to REGULAR UNLEADED /L 2 PETROLEUM 3 DIESEL ❑ 6 AVIATION GAS ❑ 60 EMPTY 6 C7 PRODUCT ❑ ib PREMIUM UNIEAOEp 4 GASAHOL ❑ 7 METHANOL ❑ 3 CHEMICAL PRODUCT ❑ 85 UNKNOWN ❑ 2 WASTE ❑ 1c MIDGRADE UNLEADED ❑ 5 JET FUEL ❑ 6 M65 D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED ❑ 2 LEADED ❑ 99 OTHER(I)FS RISE IN ITEM D.SELOM III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.B,AND C,AND ALL THAT APPLIES IN BOX D AND E C.A.S.p A. TYPE OF ❑ 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR UNER SYSTEM 2 SINGLE WALL ❑ El INTERNAL BLADDER SYSTEM ❑ 95 UNKNOWN 4 SINGLE WALL IN A VAULT ❑ 99 OTHER B. TANK I BARE STEEL ❑ 2 STAINLESS STEEL MATERIAL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ B 100% METHANOL COMPATIBLE W/FRP (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER C.INTERIOR ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING LINING OR Tom,/ ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING ❑ 5 GLASS LININGI]Q I UNLINED COATING JW`� ❑ 95 UNKNOWN El 99 OTHER IS LINING MATERIAL COMPATIBLE WITH.EXTERIOR 100% METHANOL? YES_ NO� D CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION81 NONE ❑95 UNKNOWN E.SPILL AND OVERFILL,6h. SPILL CONTAINMENT WSTALLED EAR) ❑ 89 OTHER DROP TUBE VESA NO OVERFILL PPLATE YES NO fuu REVENT) EOUIPMENTINSTALLED(YEAR) W. PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR UgIF UNDERGROUND,BOTH IF APPLICABLEDISPENSER CONTAINMENT YES- NO A. SYSTEM TYPE A SUCTION A U 2 PRESSURE B. CONSTRUCTION A A U 3 GRAVITY A U 4 FLEXIBLE PIPING A 1 SINGLE WALL A U Z DOUBLE WALL U 89 OTHER 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 PROTECTION A GALVANIZED STEEL A U 10 CATHODIC PROTECTION T STEEL 5 COATING A U 6 100% METHANOL COMPATIBLE W/FRP D. LEAK DETECTION ❑1 MECIUDA UNE!FN( 2 DNE 11GxTNEEa ❑9 LpmN90US IMERSRRALA❑15ELECmONO UNE 5 AurONAn9pV�OTHER oETEcroA TEsnxs V.TANK LEAK DETECTION owroRlxG ESX�reeTaI ❑ 54UTDOWi/ ❑ 99 OTHER 11 1 VISUAL CHECK MANUAL ❑ 7 CONTINUOUS NTERSTITIAL 2 RECONCILIATIONORY ❑ 3 MONITORING ❑ GAUGING ❑ 4 AUTOMATIC TANK 5 GROUND WATER 6 ANNUAL TANK MONITORING ❑ B SIR ❑ 9 WEEKLY MANUAL ❑10 MONTHLY TANK MONITORING TESTING VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) GAUGING TESTING ❑ 95 UNKNOWN ❑99 OTHER I.ESTIMATE =RTE LAS USED( /p yryq) 2.ESTIMATEp QUANTITY OF ]] SUBSTANCE REMAINING 4300 3.WAS TANK FILLED TERIAL?WITH GALLONS INERT MATERIAL? YES ❑ NO J� THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUEAND CORRECT TANK OWNER'S NAME T 'A WELI B SIGNATURE) DATE LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY p JURISDICTION 8 FACILITY p STATE TANKp PERMIT NUMBER lI Jr5I ZTrSt -LJ PERMIT APPROVED BV/DATE PERMIT EXPIRATION DATE THIS FORM MUST BE ACCOMPANIED BY PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. FORM C MUST BE COMPLETED FOR INSTALLATIONS. THI FORM 6 (695) SHOULD BE ACCOMPANIED BY A PLOT PULE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UMGROUID I TORyGE TANK RE ULATIONS S FORM