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STATE OF CALIFORNIA ^tao",cis cot STATE WATER RESOURCES CONTROL BOARD o UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B �d� m COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ON ONE REM F-] 2 INTERIM PERMIT F--] 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ® 8 TANK REMOVED ) DBA OR FACILITY NAME WHERE TANK IS INSTALLED: Jam S A S l CJ I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A OWNER'S TANK I.D.# Unknown 3 B. MANUFACTURED BV: Unkn n C. DATE INSTALLED(MOIDAYNEAR) D. TANK CAPACITY IN GALLONS: 6, 000 II.TANK CONTENTS IF A-1 IS MARKED,COMPLETE ITEM C. A ® 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C. 1aREGULAR UNLEADED ❑ 3 DIESEL [:] 6 AVIATION GAS F72 PETROLEUM ❑ 80 EMPTY 1 PRODUCT ❑ 1b PREMIUM UNLEADED ❑ 4 GASAHOL ❑ 7 METHANOL ❑ Ic MIDGRADE UNLEADED ❑ 5 JETFUEL ❑ 8 M85 ❑ 3 CHEMICAL PRODUCT E] 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED ❑ 99 07HEfl(DESCRIBE IN REM D.BELOlS? 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 E� 2 SINGLE WALL ❑ 4 SINGLE WALL IN A VAULT ❑ 99 OTHER B. TANK 10 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 UNING ❑ 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 E5d95 UNKNOWN ❑ 99 OTHER E.SPILL AND OVERFILL,6LC. 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 2 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION A V 1 SINGLE WALL A 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)AI(LJ 4 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEELVY A U 8 10011. 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 [:]' 6ECRANICAL LINE LEA( 2 UNE MESS 3 CONTINUWS IWEASTMk ❑4 EIEC IC UNE ❑5 AUTONNTIC PUMP OETEmOR ❑ TN TESTING ❑ MONITORING IEV!DEnamPt SNUTOOWN ❑ 99 OTHER V.TANK LEAK DETECTION ��qq jj�� ❑ 1 VISUAL CHECK 2 MANUAL INVENTORY ❑ 3 MONITORING ❑ 4 GAUGING M( TANK ❑ 5 MON TORINGTER 2C-� 6 TESTING ANNUALTANK ❑ 7 CONTINUOUS MONITORING INTERSTTIAL 9 SIR ❑ 9 TANK GAUGINGAL ❑10 MOT HLY TANK E] 95 UNKNOWN ❑99 OTHER TESNG VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) 1.ESTIMATED DATE LAST USED(MO/DAY/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 ND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT TANK OWNER'S NAME DATE (PRINTED a SIGNATURE) I- LOCAL AGENCY USE ONLY E STATE I.D.NUMBER IS COMPO OF HE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY# a TANK*60:3 STATE I.D:# 3 1 b (o PERMIT NUMBER PERMIT APPROVED BYIDATE PERMIT EXPIRATIODA E Iz I s9 9002 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 I STALLATIONS.THIS FORM SHOULD BE ACCOMPANIED BY A PLOT PLWLE THIS FORM WITH THE LOCA/ AGENCY IMPLEMENTING�{I�IERGROUND STORAGE TANK REGULATIONS FORM B (6-95) (/y