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STATE OF CALIFORNIA ��ao�,�.�` STATE WATER RESOURCES CONTROL BOARD ey UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B �� m° i COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION n 74ERMANENTLY CL SITE ONE REM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE LLFkr 8 TANK REMOVE DBA OR FACILITY NAME WHERE TANK IS INSTALLED: o Cti. I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A OWNER'S TANK I.D.# B. MANUFACTURED BY: C. DATE INSTALLED(MO/DAWYEAR) D. TANK CAPACITY IN GALLONS: H.TANK 9ONTENTS IF A-1 IS MARKED,COMPLETE ITEM C. A 1 MOTOR VEHICLE FUEL ❑ 4 OIL 8. C. ❑ to REGULAR UNLEADED ❑ 3 DIESEL ❑ 6 AVIATION GAS F72 PETROLEUM E:] 80 EMPTY [TI1 PRODUCT ED 1b PREMIUM UNLEADED ❑ 4 GASAHOL ❑ 7 METHANOL c MIDGRADE UNLEADED ❑ 5 JET FUEL ❑ 8 M85 ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE 2 LEADED ❑ 99 OTHER(DESCRIBE IN REMD.BELOM 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 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 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 UNED ❑ 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 CATHODICPROTECTION ❑ 91 NONE E]95 UNKNOWN ❑ 99 OTHER E.SPILL AND OVERFILL,BSC. 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 A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL A U 2DOUBLE 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 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTIONINIE 1 411 1q UNE LEOK 2 UNE HTNE53 3 CWTNUWS RSTTAL 4 ELECTRONIC UNE 5 AOT0Wn0 PWP ❑ DkTECTOR ❑ TESTNG TK: ❑ WWMING ❑ UMK DETECTOR ❑ 51AT m ❑ 99 OTHER V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 MANUAL RECONCILIATIONORV ❑ 3 VAOZEMONIITORING ❑ 4 GAUGINAUTOMATG MONITORING TANK ❑5 GROUND MONTORING�R ANNUAL TANK ❑ 6 TESTING ❑ 7 MONITORING INTERSTITIAL ❑ 8 SIR ❑ 8 TANK GAUGINGAL ❑10 MOTESNTHLY TANK ❑ 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) 1.ESTIMATED DATE LAST USED MONDAY R) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES NO -"7 SUBSTANCE REMAINING GALLONS INERT MATERIAL? ❑ ❑ THIS FORM HAS BEEN CO PLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT TANK OWNER'S NAME DATE (PRINTED 6 SIGNATURE) LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY# � TANK# STATE LD:# I=3L � 0-1 h PERMIT NUMBER PERMIT APPROVED BWDATE PERMIT EXPIRATION DATE THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLIN•FORM A,UNLESS A CURRENT FORMA HAS BEEN FILED. FOMUST BE COMPLETED FOR INSTALLATIONS.THIS FORM SHOULD BE ACCOMPANIED BY A PP LE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE GROUND STORAGE TANK REGULATIONS FORM B (6-95) LOT