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STATE OF CALIFORNIA • '`60 8 C M1' STATE WATER RESOURCES CONTROL BOARD 3 e, � '. ; UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B ; - COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. ❑ 7 PERMANENTLY CLOSED ON SIT MARK ONLY ❑ ❑1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ONE REM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVEDFb DBA OR FACILITY NAME WHERE TANK IS INSTALLED: b 3 L l l �• I. TANK DESCRIPTION COMPLETE ALL ITEMS— SPECIFY IF UNKNOWN A OWNER'S TANK I.D.N Q / B. MANUFACTURED BY: D. TANK CAPACITY IN GALLONS: C. DATE INSTALLED(MO/DAY/YEAR) II.TANK CONTENTS IF A-1 IS MARKED,COMPLETE ITEM C. ❑ 1a REGU AR UNLEADED ❑ 3 DIESEL ❑ 6 AVIATION GAS A ❑ 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C. ❑ 1G PREMIUM UNLEADED ❑ 4 GASAHOL ❑ 7 METHANOL ❑ 2 PETROLEUM ❑ 80 EMPTY ❑ 7 PRODUCT ❑ Ic MIDGRADE UNLEADED ❑ 5 JET FUEL ❑ 8 M85 ❑ 3 CHEMICALPRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED ❑ 99 OTHER(DESCRIBE IN ITEM D.BELOM D. IF(Ai)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 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 n[1 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B. TANK C''� ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP MATERIAL ❑ 5 CONCRETE (primary Tank) ❑ 9 BRONZE ❑ 10 NO STEEL ❑ 95 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING C.INTERIOR LINING OR ❑ s GLASS LINING X6 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES— NO.X D.EXTERIOR ❑ 1 POLYETHYLENE WRAP P 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC CORROSION gl NONE ❑ 95 UNKNOWN ❑ 99 OTHER PROTECTION ❑ 5 CATHODIC PROTECTION SPILL CONTAIN MEM INSTALLED(YEAR) OVERFILL PREVENTION-EQUIPMENT SPEINS ER CON AINM E.SPILL AND OVERFILL,bit. NO AIKER PLATE YES__ NO__ DISPENSER CONTAINMENT VES_ NO,_. DROPTUBE YES_ IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A 1 SUCTION A U 2 PRESSURE A 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 1 BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A U 4 FIBERGLASS PIPE CORROSION A 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 MECHII4CAL UNE LEAI( 2 ONE BaHiNE55 ❑3 cO WWS INIERSTTIAL ❑4 NI�GRE ❑5 S4UTWtVN P9MP ❑ 99 OTHER 'C. D. LEAK DETECTION ❑ GETEOTOR ❑, TEsnNa UMTGRM V.TANK LEAK DETECTION ��yy��((( 'L�y 2 MANUAL INVENTORY ❑ 3 MONOITORING ❑ 4 GAUGINGAUTOMATIC TANK ❑ 5 GROUND MONITORING TESTING ANNUAL TANK ❑ 1 VISUAL CHECK f-1 8 SIR ONCIUATION ❑ 9 WEEKLY MANUAL ❑10 MONTHLY TANK ❑ 95 UNKNOWN ❑99 OTHER ❑ 7 CONTNUOUS INTERSTITIAL LJ TANK GAUGING TESTING MONITORING VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH VES ❑ NO 1.ESTIMATED DATE LAST US D(MO/DAY/YR) SUBSTANCE REMAINING GALLONS INERT MATERIAL? PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF TANK OWNER'S NAME (PRINTED d SIGNANRE) LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY a 3C(LI3 TANK# STATE I.D.# L J J J � 3 1 � EPERMITMBER E;;1 PERMIT APPROVED BV/DATE PERMIT EXPIRATION DATE MPLETED FOR THIS FORM MUSTSHOULD BE ACCOMPANIED BY AI PLOT PICWILE TOHIS RM FORM WITH THE LOCAL AGE UNLESS A CURRENT FORM CY MPL MENTING THE R GROUN3'- 13- '?g A HAS BEEN FILED. FORM C MUST BE OTOI GE TANK REGULATIONS THIS FORM FORM B (6-95) 3