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CgpU�Ctp STATE OF CALIFORNIA rpif STATE WATER RESOURCES CONTROL BOARD ; o UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B • ��L Grp M1N� COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION PERMANENTLY C ED ON ONE REM K2 INTERIM PERMIT 4 AMENDED PERMIT E] 6 TEMPORARY TANK CLOSURE TANK REMOV DBA OR FACILITY NAME WHERE TANK IS INSTALLED: I. TANK DESCRIPTION COMPLETE ALL ITEMS-- SPECIFY IF UNKNOW A OWNER'S TANK I.0.N B. MANUFACTURED BY: C. DATE INSTALLED(MOIDAYNEAR) D. TANK CAPACITY IN GALLONS: 6Z'o 11.TANK CONTENTS IF A- MARKED,COMPLETE ITEM C. A, ❑ 1 MOTOR VEHICLE FUEL ❑ 4 OIL B, C 1a REGULAR UNLEADED ❑ 3 DIESEL ❑ 6 AVIATIONGAS �/ 1h PREMIUM UNLEADED ❑ 4 GASAHOL 7 METHANOL �FPETROLEUM ❑ 80 EMPTY I_ .1`1 PRODUCT ❑ 1e MIDGRADE UNLEADED ❑ 5 JET FUEL E::] 8 M85 ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ` j 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.0: 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 ❑ 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 5 INTERNAL BLADDER SYSTEM ❑ 95 UNKNOWN SYSTEM G2r2 SINGLE WALL O 4 SINGLE WALL IN A VAULT ❑ 99 OTHER B. TANK 2r1 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 WJFRP (Primary Tank) a 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 G 6 UNLINED ,❑ 95 UNKNOWN ❑ 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 1001/6 METHANOL? YES_ NO— D'EXTERIOR ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC CORROSION � PROTECTION ❑ 5 CATHODIC PROTECTION L2J 91 NONE ❑95 UNKNOWN ❑ 99 OTHER E.SPILL AND OVERFILL,etc. SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) / DROP TUBE YES a�NO STRIKER PLATE YES NO �C DISPENSER CONTAINMENT YES NO `/ IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OT14ER B. CONSTRUCTION AeS 1 SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND ACgL1 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 WI COATING A U 8 100% METHANOL COMPATIBLE WIFRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION ❑1 MECHANICAL UNE LEAN 2 UNE TIGHTNESS 3 CONTINUDUS INTERSTMAL 4 ELECTRONIC LINE 5 ALROMATIC PUMP DETECTOR ❑ TESTING ❑ MONITORING ❑ LEAK L7ETECTOR SHUTD05YN 99 OTHER V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 MANUAL RECONCILIATION INVENTORY [—] 3 VAOZEMOH ORING ❑ 4 GAUG NGAUTOMATIC TANK E:] 5 MONITORINGTER ❑ 6 TGROUND ESTINGTANK ❑ 7 MONITORING INTERSTITIAL ❑ 8 SIR ❑ 9 TANK GAUGINGAL ❑ 10 TEST NGY TANK 95 UNKNOWN E] 99 OTHER VI.TANK CLOSURE INFORMATION(PIERMANENT CLOSURE IN-PLACE) I.ESTI ATEO DATE LAST USED(MO)CAYlYR) -2:ESTIMATED OUANTITY OF 3.WAS TANK FILLED WITH YES ❑ NO f. " SUBSTANCE REMAINING "� GALLONS INERT 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 //�� ///fff DATE r (PRINTED651GNATURE) /� LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY# q <# pO Q STATE 104m l� o LD PERMIT NUMBER PERMIT APPROVED BYIDATE PERMIT EXPIRATION DATE f�-{a THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLI(' ON-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. FO C MUST BE COMPLETED FOR INSTALLATIONS. THIS FORM r SHOULD BE ACCOMPANIED BY A PLOT P LE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THEGROUND STORAGE TANK REGULATIONS FORMS (6.95)