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• 0 STATE OF CALIFORNIA ^`�oU^�ey STATE WATER RESOURCES CONTROL BOARD^ coj'o UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B mP� m a I : . 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 ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED O DBA OR FACILITY NAME WHERE TANK IS INSTALLED: 11so MAI ST M I. TANK DESCRIPTION COMPLETE ALL ITEMS– SPECIFY IF UNKNOWN A OWNER'S TANK I.D.# I B. MANUFACTURED BY: C. DATE INSTALLED(MO/DAYNEAR) U D. TANK CAPACITY IN GALLONS: I 000 II.TANK CONTENTS IF A-1 IS MARKED,COMPLETE ITEM C. A, ❑ 1 MOTOR VEHICLE FUEL ❑ 4 OIL 8. C, ❑ is REGULAR UNLEADED ❑ 3 DIESEL ❑ 6 AVIATION GAS ❑ 2 PETROLEUM ❑ SO EMPTY ❑ 1 PRODUCT ❑ 1b PREMIUM UNLEADED ❑ 4 GASAHOL 7 METHANOL ❑ Ic MIDGRADE UNLEADED ❑ 5 JET FUEL ❑ 8 M85 ❑ 3 CHEMICALPRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED ❑ 99 OTHER(DESCRIBE IN ITEM D.BELOW) D. IF(A1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S.#: 111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A,B,AND C,AND ALL THAT APPLIES IN BOX D AND E A. TYPE OFF—] 1 DOUBLE WALL F—] 3 SINGLE WALL WITH EXTERIOR LINER 5 INTERNAL BLADDER SYSTEM F] 95 UNKNOWN SYSTEM --�jj 2 SINGLE WALL ❑ 4 SINGLE WALL IN A VAULT ❑ 99 OTHER B. TANK NM 1 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 W/FRP (Primary Tank) ❑ 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 ❑ 6 UNLINED 95 UNKNOWN ❑ 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES— NO— D.EXTERIOR ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC CORROSION PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER E.SPILL AND OVERFILL,etc. 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 1 SUCTION A U 2 PRESSURE U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION A 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 7 STEEL W/COATING A U 8 100% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U /0 CATHODIC PROTECTION AU 5 UNKNOWN A U 99 OTHER D. LEAK DETECTION 1 AIELIUNICAL UNE t 2 UNE TIGHTNESS 3=MNUWS INTERSTITIAL 4 ELECTRONIC UNE 5 AUfONATIC PU6P ❑ DETECTOR ❑ TESTING ❑ #ONTIXVWG ❑ LEAK GEIECTOR � SHUTDOWN ❑ 99 OTHER V.TANK LEAK DETECTION ❑ t VISUAL CHECK ❑ 2 RECONCILANUAL IIATIONVENTORY ❑ 3 MONITORING VAEO 4 GAUGINAUTOMATG TANK ❑5 MONTORINGGROUND TER ❑ 6 TESTINGANNUAL ❑ 7 MONITORING NUOUS INTERSTITIAL ❑ 8 SIR ❑ 9 TANK GAUGINGAL ❑ 10 MOSNTHLY TANK O 95 UNKNOWN ❑99 OTHER TING VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) 1.ESTIMATED DATE L4S7jUSED( O/DAY/YR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH �S SUBSTANCE REMAINING GALLONS IN MATERIAL? YES E::] 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 DATE (PRINTED d SIGNATURE) LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY#31q TANK# (NJ STATE I.D:# Z 6 2 3 2 3 3 2 FZF31SIZ110111 PERMIT NUMBER PERMIT APPROVED BYIDATE PERMIT EXPIRATION DATE /` I toll q THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPL��L��$$QQQQQQN-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. FgW MUST BE COMPLETED FOR INSTALLA ONS. THIS FORM SHOULD BE Ar'; P OMPANIED BY A PLOT ILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING TH v RGROUND STORAGE TANK REGULATIONS FORM B (6-95) ''