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STATE OF CALIFORNIA • .•" �.� ti STATE WATER RESOURCES CONTROL BOARD 3 UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B ( COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ONSITE ONE REM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: Cka-, 5r SS O D7 6 I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A OWNER'S TANK 1.0.♦ 7j B. MANUFACTURED BY: G LA. &- QYyY�2 C. DATE INSTALLED(MO/DAY/YEAR) l D. TANK CAPACITY IN GALLONS: 0 II,TANK CONTENTS IFA-1 IS MARKED.COMPLETE ITEM C. A �1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C. 1S REGULAR UNLEADED ❑ 3 DIESEL ❑ 6 AVIATIONGAS ❑ 2 PETROLEUM ❑ 80 EMPTY 1 PRODUCT 1b PREMIUM UNLEADED ❑ 4 JET FUEL ❑ 7 METHANOL ❑ 11 MIOGRADE UNLEADED ❑ 5 JET FUEL ❑ 8 M85 ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED ❑ 99 OTHER(DESCRIBE IN DEMD.BELONG D. IF(A1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S.N 111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.8,AND C,AND ALL THAT APPLIES IN BOX D AND E A. TYPE OF Idl 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 5 INTERNAL BLADDER SYSTEM ❑ 95 UNKNOWN SYSTEM ❑ 2 SINGLE WALL ❑ 4 SINGLE WALL IN A VAULT ❑ 99 OTHER B. TANK ❑ 1 BARE STEEL ❑ 2 STAINLESS STEEL 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 8 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP (PHRMryTwk) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER C.INTERIOR ❑ 1 RUBBER UNED ❑ 2 ALKYD LINING ❑ 3 EPDXY UNING ❑ 4 PHENOLIC LINING LINING OR ❑ 5 GLASS LINING 8 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH IDD% METHANOL? YES— NO_ D.EXTERIOR ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC CORROSION91 NONE 95 UNKNOWN 99 OTHER PROTECTION ❑ 5 CATHODIC PROTECTION ❑ ❑ ❑ SPILL CONTAINMENT IN ALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEA E.SPILL AND OVERFILL,BLC, DROP TUBE YES NO. STRIKER PLATE YES�NO DISPENSER CONTAINMER)N YES NO IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION A/6)_2 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLEPIPING A U 99 OTHER B. CONSTRUCTION A U I SINGLE WALL A 2 DOUBLE WALL A U 3 UNED 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) FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL W/COATING A U 8 100% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER - 1 MECRWCAL UNE SAK2 LINE TNHI % 3 CONIINUWS INIERSTIRAL 4 EIECMOMC UNE 5 AVICLMTC PUW ❑ 99 OTTER D. LEAK DETECTION ❑ dam ❑ IEmM1 WMTWING UmOE1ECT011 $XUfD0V4/ V.TANK LEAK DETECTION �/ ❑I 1 VISUAL CHECK IyJ 2 RECONCILIATIONNUAL INVENTORY ❑ 3 MAON�ITORING ZE 4 GAUGING AUTOMATIC TANK ❑ 5 MONITORINGGROUNDWATER ❑8 ANNUAL TESTINGTANK `�-� 7 MONITORING INTERSTITIAL ❑ 8 SIR ❑ B WEEKLY TANK GAUGING ❑ 10 TESTING TANK ❑ 95 UNKNOWN ❑99 OTHER VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PUCE) 1.ESTIMATED DATE LAST USED(MO/DAY/YR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES ❑ NO❑ SUBSTANCE REMAINING GALLONS INERT MATERIAL? hrlIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO HE BEST OF MY KNOWLEDGE,IS TRU AN CORRECT -XAMK-9WNER'S NAME DATE LPRLNsly_RET O LOCAL AGENCY USE ONLY THE STATE I .N BER IS COMPOSED OF THE FOUR NUMBERS BELOW COUN k JURISDICTION M FACILITY# TANK N STATE 01 m F-T-F-= PERMIT NUMBER PERMIT APPROVED BYIDATE PERMIT EXPIRATION DATE THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPUON-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 FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THIVRGROUND STORAGE TANK REGULATIONS FORM B (EBS)