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STATE OF CALIFORNIA •'°'u"" STATE WATER RESOURCES CONTROL BOARD °c 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 ON SITE ONE REM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: /'ZD `y f"�S ice. I. TANK DESCRIPTION COMPLETE ALL ITEMS– SPECIFY IF UNKNOWN A OWNER'S TANK I.D.N (/ B. MANUFACTURED BY: C. DATE INSTALLED(MO/DAYNEAR) �� 9 D. TANK CAPACITY IN GALLONS: Dt� II.TANK CONTENTS IFA-1 IS MARKED,COMPLETE ITEM C. A MOTOR VEHICLE FUEL ❑ 4 OIL B. C. ❑ 1a REGULAR UNLEADED DIESEL ❑ 6 AVIATION GAS 2 PETROLEUM ❑ SO EMPTY PRODUCT ❑ iG PREMIUM UNLEADED 4 GASAHOL ❑ 7 METHANOL ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN F2 Wq$7E ❑ 1O MIDGRADE UNLEADED 5 JET FUEL ❑ 8M85 ❑ 2 LEADED ❑ 99 OTHER(DESCRIBE IN ITEM D.BE: LOM IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C. 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 2 SINGLE WALL ❑ 4 SINGLE WALL IN A VAULT ❑ 99 OTHER B. TANK ❑ 1 BARE STEEL ❑ 2 STAINLESS STEEL3 FIBERGLASS ED4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL E] 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP (Primary Tank) ❑ y 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 LININGUNLINED E] 95 UNKNOWN ❑ 99 OTHER COATING IS LINING MATERIAL COMPATIBLEITH 100°.6 METHANOL? YES_ NO— D.EXTERIOR ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING CORROSION ❑❑ 3 VINYL WRAP �d FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE 95 UNKNOWN 99 OTHER E.SPILL AND OVERFILL,6TC. SPILLOP CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) DRNBE VES_ 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 1 SUCTION PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION A U i SINGLE WALL 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 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 p U 99 OTHER D. LEAK DETECTION LZ M2CIWIICAL UNE OF ❑2 UNE TKSNrAESS ❑3 CWINUWS(N RS fflk ❑e ELEcmaMc uNE ❑5 AuroMAnc vuw mmt7oR TESTING MONTORMKi LEAK OE Mfl SNVTOOWN ❑ 99 OTHER V.TANK LEAK DETE16TION ❑ 7 CONTINUOUS INTERSTITIAL 2 MANUAL RECONCILIATION MONITORING ❑ 3 VADOZE MONIITORING ❑ 4 AUTOMATGAUGING MONITORING TANK ❑ 5 GROUND MONTORINGTER ❑6 TESTINGTANK MONITORING ❑ B SIR ❑ 9 WEEKLY MANUAL D 1 MONTHLY TANK ❑ 95 UNKNOWN ❑99 OTHER TANK GAUGING TESTING VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) 1.ESTIMATED DATE LAST USED(MO/DAY/YR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH SUBSTANCE REMAINING GALLONS INERT MATERIAL? 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 d SIGNATURE) DATE LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW STATE I.D:# COUNTY# JURISDICTION# FACILITY# TANK# TI�I I I PERMIT NUMBER m L�W �// PERMIT APPROVED BY/DATE PERMIT EXPI TION DATE THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPUC""QQN-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. F MUST BE COMPLETED FOR INSTALLATIONS. THIS FORM FORMS (6.95) SHOULD BE ACCOMPANIED BY A PLOT PLVLE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THEJWGROUNDSTORAGE TANK REGULATIONS