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W cE9 STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD ~o UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B ma i 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 ITEM ❑ 2 INTERIM PERMIT O 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: oq-&- - 6lN I. TANK DESCRIPTION COMPLETE ALL ITEMS— SPECIFY IF UNKNOWN A OWNER'S TANK I.D.# i I / B. MANUFACTURED BY: i / �A\ I V w f C. DATE INSTALLED(MO/DAYNEAR) D. TANK CAPACITY IN GALLONS: I O V PV IL TANK CONTENTS IFA-1 IS MARKED,COMPLETE ITEM C. A 1 MOTOR VEHICLE FUEL 4 OIL B. C. ❑ la REGULAR UNLEADED 3 DIESEL ❑ 6 AVIATION GAS ❑ 2 PETROLEUM ❑ 80 EMPTY 7 PRODUCT ❑ lb PREMIUM UNLEADED ❑ 4 GASAHOL ❑ 7 METHANOL ❑ lc MIDGRADE UNLEADED 5 JET FUEL 8 M85 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ ❑ ❑ ❑ 2 LEADED ❑ 99 OTHER(DESCRIBE IN REM D.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 \�❑I 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 F7 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 LINING ❑ 4 PHENOLIC LINING LINING OR ❑ 5 GLASS LINING ❑ 6 UNLINED 95 UNKNOWN ❑ 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 10096 METHANOL? YES_ NO— D.EXTERIOR ❑ 1 POLYETHYLENE WRA ❑ 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC CORROSION PROTECTION ❑ 5 CATHODIC PROTECTION 91 NONE ❑ 95 UNKNOWN 99 OTHER E.SPILL AND OVERFILL,Bic. 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 AID 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 2 DOUBLE WALL A U 3 LINED TRENCH <7>5 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 U 5 UNKNOWN A U 99 OTHER D. LEAK DETECTION1 uEalN UNE LEAK 2 UNE V(affKM 3 CONnxUWS WMnRk 4 BEc IC UNE 5 AurouAnc roup ❑ OETECNR ❑ TEETNG ❑ MONnORINO ❑ LENt DETE m ❑ SHMMM ❑ 99 OTHER V.TANK LEAK DETECTION ❑ i VISUAL CHECK 2 RECONCILIATIONNUAL INVENTORY ❑ 3 VAOZEMONIITORING ❑ 4 GAUGING AUTOMATIC TANK ❑ 5 MONITORINGGROUND 8 ANNUAL TESTINGTANK ❑ 7 MONITORING G INTERSTITIAL O B SIR ❑ 9 WEEKLY MANUAL ❑ 10 MONTHLY TANK O g5 UNKNOWN ❑99 OTHER TANK GAUGING TESTING VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PUCE) 1.ESTIMATED DATE LA T US D O/DAY/YR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH VES ND❑ Z Z SUB STANCE REMAWING GALLONS NERT 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 d SIGNATURE( LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY#00 YO.1 TANK# () STATE I.D:# 3 4 = I I e ER5 1p N2/ 9 PERMIT NUMBER PMIT APPROVED BYiDATE PERMIT ON T 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 RLE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING T*ERGROUND STORAGE TANK REGULATIONS FORMS (fi-95)