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• • STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD �� m UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ON SITE ONE REM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE 8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: m I. TANK DESCRIPTION COMPLETE ALL ITEMS– SPECIFY IF UNKNOWN A. OWNER'S TANK I.D.# 'J B. MANUFACTURED BY: f� G+ C. DATE INSTALLED(MO/DAY/YEAR) D. TANK CAPACITY IN GALLONS: LI. II.TANK CONTENTS IF A-1 IS MARKED,COMPLETE ITEM C. p 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C. ❑ 1a flEGULAR UNLEADED ❑ 3 DIESEL ED AVIATION GAS ❑ 2 PETROLEUM ❑ 80 EMPTY \❑ 1 PRODUCT \ �❑ 1b PREMIUM UNLEADED ❑ 4 GASAHOL ❑ T METHANOL ❑ 8 M85 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE �I 2 LEAD DE UNLEADED O 9UET FUEL ❑ 9 OTHER(DESCRIBE IN ITEM D.BELOW) D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED I� C.A.S.0: 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 \T❑-I I DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 5 INTERNAL BLADDER SYSTEM ❑ 95 UNKNOWN SYSTEM I�J 2 SINGLE WALL ❑ 4 SINGLE WALL IN A VAULT ❑ 99 OTHER S. TANK ❑ 1 BARE STEEL ❑ 2 STAINLESS STEEL 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL 7 5 CONCRETE 6 POLYVINYL CHLORIDE 7 T 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 UNING MATERIAL COMPATIBLE WITH 100°.6 METHANOL? YES— NO— D.EXTERIOR ❑ 1 POLYETHYLENE WRA ❑ 2 COATING F-] 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC CORROSION PROTECTION ❑ 5 CATHODIC PROTECTION 91 NONE ❑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 YES_ NO IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE U 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 A(1)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)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 AQ0 UNKNOWN A U 99 OTHER 1 MECXN#GL DNE LEAK 2 UNE MWKSS 3 WKrNUWS INTERSTRUL 4 ELECTRONIC UNE 5 AUTOIMTIC PUMP D. LEAK DETECTION ❑ DETECTOR ❑ TESnNO MOMTWMO LEAK DETECTOR S4UTWWN ❑ 99 OTHER V.TANK LEAK DETECTION 1 VISUAL CHECK 2 MANUAL NG RECONCI INVENTORY ❑ 3 ATION MONOITORING ❑ 4 GAUGINGAUTOMATIC TANK ❑ 5 MON D WATER 8 ��NGTANK ❑ 7 MONITORING INTERSTITIAL ❑ 8 SIR ❑ 9 WEETANK LY MANUAL ❑10 MONTHLYTESTING TANK ❑ 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) 1.ESTIMATED DATE ST USED(MOIDAYNR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES ❑ NO ❑ �Z SUBSTANCE REMAINING GALLONS INERT MATERIAL 7 THIS FORM FAS BEEN COMPLETED UNDE 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 COUmNN# JURISDICTION# FACILITY TANK#Q STATE I.D:# 6 PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRAT12 7^ 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 PIIWILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE&RGROUND STORAGE TANK REGULATIONS FORM B (6-95)