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STATE OFCALIFORNIA • • �� `S, STATE WATER RESOURCES CONTROL BOARD 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 O 4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE O 8 TANK REMOVED 1 DBA OR FACILITY NAME WHERE TANK IS INSTALLED: I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A OWNER'S TANK I.D.# / f B. MANUFACTURED BY: alnc �� C. DATE INSTALLED(MG(DAYNEAR) D. TANK CAPACITY IN GALLONS: IL TANK CONTENTS IF A-/IS MARKED,COMPLETE ITEM C. A. ❑ 1 MOTOR VEHICLE FUEL 4 OIL B. C. 1a REGULAR UNLEADED ❑ 3 DIESEL ❑ 6 AVIATION GAS ❑ 2 PETROLEUM 80 EMPTY 1 PRODUCT ❑ 1b PREMIUM ❑ UNLEADED ❑ 4 GASAHOL ❑ 7 METHANOL ❑ E::] ❑❑ 2G MEAD DE UNLEADED O 99 JETFUELOTH R(DESCR❑ 8 M85 IBE IN ITEM D.BELOW) 3 CHEMICAL-PRODUCT 95 UNKNOWN 2 WASTE D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED o. ctS C.A S.#: D 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. TANKi BARE STEEL F-12 STAINLESS STEEL E] 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ff❑ 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 ❑ I RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING LINING OR [:] 5 GLASS LINING I- 6 UNLINED [:] 95 UNKNOWN E::] 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO-VI D.EXTERIOR ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC CORROSION PROTECTION ❑ 5 CATHODIC PROTECTION 91 NONE E]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 S 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 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION CUJ SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND 1J1 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 DETECTION ❑1 MECNIMCM ME IEAI( �2 ME TIGHTNESS �3 CONRNUWS INTERETiML ❑4 EIEGIRWIC UNE E]5 AUTOMATIC PUMP ❑ 99 OTHEP DETECTOR TESTING MMTq IUK OEIECTOR SHUi00WN V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 MANUAL RECONCILIATION INVENTORY COCILIATIONORY ❑ 3 MONIITORING VAOZEE::] 4 GAUGINAUTOMATG MONITORING TANK ❑ 5 MONTORINGGROUND 7ER F78 TESTINGANNUAL TANK E] 7 COMON TOR U INTERSTITIAL O 8 SIR ❑ 9 WEEK LY MANUAL E]10 TESTINGLY TANK E] 95 UNKNOWN 99 OTHE VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) 1.ESTIMATED DATE T USED(MOIDAY/YR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES ❑ NO❑ SUBSTANCE REMAINING GALLONS INERT MATERIAL? 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 6 SIGNATURO LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY# K# STATE I.D:# m s 3 S 3 y (o PERMIT NUMBER PERMIT APPROVED BV/DATE PERMIT EXPIRATION DATE /0 THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. FORM C MUST BE COMPLETED R INSTALLATIONS. THIS FORM SHOULD BE ACCOMPANIED BY A PLOT P RLE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TA K REGULATIONS FORMS (6-95) 0 FORW34&R7