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w - STATE OF CALIFORNIA a • PW STATE WATER RESOURCES CONTROL BOARD r /UNDERMI OUND STORAGE TANK PERMIT APPLICATION - FORM B COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. ` MARK ONLY I NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION T PERMANENTLY E 0 SITE ONE REM O 2 INTERIM PERMIT O 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE t;l-<TANK REM D DBA OR FACILITY NAME WHERE TANK IS INSTALLED: I. TANK DESCRIPTION COMPLETE ALL ITEMS– SPECIFY IF UNKNOWN A OWNER'S TANK I.D.• I B. MANUFACTURED BY: C. DATE INSTALLED(MO/DAY/YEAR) D. TANK CAPACITY IN GALLONS: II.TANK C TENTS IF A-1 IS MARKED,COMPLETE ITEM C. 11 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C. ❑ la REGULAR UNLEADED ❑ 3 DIESEL ❑ 6 AVIATION n A' ❑ lE PREMIUM UNLEADED ❑ 4 GASAHOL ❑ T METHANOL ❑ 2 PETROLEUM ❑ 80 EMPTY 1 PRODUCT ❑ Ic MIDGRADE UNLEADED ❑ 5 JETFUEL E::] 8 MBS ❑ 3 CHEMICAL PRODUCT E::] 95 UNKNOWN ❑ 2 WASTE O 2 LEADED ❑ 99 OTHER(DESCRIBE IN REM D.BELO 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 �U1� A. TYPE OF ❑ I DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 5 INTERNAL BLADDER SYSTEM ❑ 95 UNKNO SYSTEM ❑ 2 SINGLE WALL ❑ 4 SINGLE WALL IN A VAULT ❑ 99 OTHER B. TANK ❑ I BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ T ALUMINUM ❑ 8 100% METHANOL COMPATIBLE WIFRP (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER C.INTERIOR ❑ I RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY UNING ❑ 4 PHENOUC LINING LINING OR ❑ 5 GLASS LINING ❑ 6 UNLINED - ❑ 95 UNKNOWN O 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH IOD% METHANOL? YES— NO— D.EXTERIOR D 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC CORROSION 91 NONE PROTECTION ❑ 5 CATHODIC PROTECTION 95 UNKNOWN❑ - ❑ El 99 OTHER E.SPILL AND OVERFILL,BIC. SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) DROP TUBE YES NO STRIKER PLATE YES_ NO DISPENSER CONTAINMENT YES NO IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U I SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION A U 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 T STEEL Wl COATING A U 8 100% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODICPROTECTION A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION ❑I MECW ICA.LINE LEAK ❑2 LINE TNHMESS ❑3 C UWS IM-ePSTTAL ❑4 ELECttroNIC LINE [:]5 AUTOMATIC PUMP ❑ 99 OTNER DETECTOR TESTING MOMTORMG LEMI DETECTOR SNUfDOM V.TANK LEAK DETECTION ❑ I VISUAL CHECK ❑ 2 MECONCILANUAL E] 3 MONITORING ❑ 4 GAUGINAUTOMATG TANK F] 5 MONITORING ❑ 8 ANNUAL TIES GROUNDWATER ❑ T CONTINNUOUCS INTERSTITIAL ❑ 8 SIR E::] 9 WEEK LY MANUAL ❑10 TES HLY TANK E:] 95 UNKNOWN ❑ 99 OTHER VI,TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) 1.ESTMATEDO TE LAST USD /DAWYR) 2.ESTIMATED QUANTITY OF I 3.WAS TANK FILLED WITH YES O NO❑ _ SUBSTANC'REMAINING GALLONS IN MATERIAL? 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 (PRWTED 4 SIGNATURE) LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION M FACILITY# T NK# ,�71) 01 STATE 01 m �m 0 PERMIT NUMBER PERMIT APPROVED BYIDATE 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 FOF SHOULD BE ACCOMPANIED BY A PLOT PI FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE 'RGROUND STORAGE TANK REGULATIONS FORMS (6-95)