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STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD % UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B I COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. NOSED OI MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ] PERMANENTLY CLOSED (�'s ONE REM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED O DBA OR FACILITY NAME WHERE TANK IS INSTALLED: P J + I, TANK DESCRIPTION COMPLETE ALL ITEMS— SPECIFY IF UNKNOWN A OWNER'S TANK I.D.# B. MANUFACTURED BY: C. DATE INSTALLED(MONAV/YEARj 3 D. TANK CAPACITY IN GALLONS: II.TANK CONTENTS IF A-1 IS MARKED,COMPLETE ITEM C. 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C, ❑ to REGULAR UNLM D 3 DIESEL ❑ 8 AVIATION GAS A ❑ 2 PETROLEUM ❑ 80 EMPTY VAI 1 PRODUCT O 1c MpOG IRADEHo ED 4 GA AHO UUNLEADED ❑ 5 JET FUEL ❑ B M65HANOL ❑ 3 CHEMICALPRODUCT ❑ 95 UNKNOWN �❑ 2 WASTE ❑ 2 LEADED ❑ 99 OTHER(DESCRIBE IN REM D.BELOW) D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S.4: 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 F—] 1 DOUBLE WALL F—] 3 SINGLE WALL WITH EXTERIOR LINER E] 5 INTERNAL BLADDER SYSTEM ❑ 95 UNKNOWN SYSTEM �2 SINGLE WALL ❑ 4 SINGLE WALL IN A VAULT ❑ 99 OTHER B. TANK LJ 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W1 FIBERGLASS REINFORCED PLASTIC MATERIAL 5 CONCRETE ❑ 8 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING C.INTERIOR ❑ LINING OR �5 GLASS LINING ❑ 6 UNLINED 95 UNKNOWN E] 99 OTHER COATING ///IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? VES X NO— D.EXTERIOR F-1 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC CORROSION 91 NONE ❑95 UNKNOWN ❑ 99 OTHER PROTECTION ❑ 5 CATHODIC PROTECTION SPILL CONTAINMENTINSTALLED LOYEA OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) E.SPILL AND OVERFILL,6TC. DROP TUBE YES_ NO RIKER PLATE YES_ NO DISPENSER CONTAINMENT VES_ NO IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM T77777777 ON A U 2PRESSURE A U 3 GRAVITY A U 4 FLEXIBLEPIPING A U 99 OTHER B. CONSTRULE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHERC. MATERIALE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A U 4 FIBERGLASS PIPECORROSIINUM A U 6 CONCRETE A U ] STEEL WI COATING A U 8 100% METHANOL COMPATIBLE W+FRP 54 PROTECTIVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER 1.. 1 MECNM'IGL LINE LEAK 2 UNE TIGNi . ❑3 CGN9N r a S.' ❑4 ELErnMC UNE ❑5 AV oMAnC PUMP 9B OTHER "I P D. LEAK DETECTION ❑ 9 aoll ❑ TESTING MGmroRmG LW DMOTOR SRuroowx V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK 2 MANUAL INVENTORY ❑ 3 VADOZEMONITORING ❑ 4 AUTOMATGAUGING MONITORING TANK ❑5 GROUND MONTORINGTER 6 TESTINGTANK RECONCILIATION ❑ ] CO NU US MON TOR NG INTERSTITIAL 6 SIR ❑ 9 TA EK GAUGINGAL ❑10 MONTHLTESTING TANK ❑ 95 UNKNOWN ❑99 OTHER VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) 1.ESTIMATED DATE LAST USED(MOIDAWYR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES [:] NO SUB STAN CE REMAINING GALLONS INERT MATERIAL THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT DATE TANK OWNER'S NAME (PRINTED d SIGNATURE) LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY# 3 TANK# eoeI- STATE I.Dl am 1 ;2131:1= % PERMIT NUMBER PERMIT APPROVED BYIDATE PERMIT EXPIRATION DATE THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. FORM C MUST BE COMPLETED FOR INSTALLATIONS.THIS FORM SHOULD BE ACCOMPANIED BY A PLOT PULE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE RGROUN STORAGE TANK REGULATIONS FORM B (6.95) 33 /�T