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STATE OF CAUFORNIA ,± STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B ;r , COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT F] 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ON SITE, ONE REM ❑ 2 INTERIM PERMIT ❑ d AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ B TANK REMOVED r ,T DBA OR FACILITY NAME WHERE TANK IS INSTALLED: I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A OWNER'S TANK 1.D.# .7r- B. MANUFACTURED BY: � C. DATE INSTALLED(MO/DAYNEAR) D. TANK CAPACITY IN GALLONS: IL TANK CONTENTS IFA-1 IS MARKED.COMPLETE ITEM C. �❑ 11 MOTOR VEHICLE FUEL ❑ 4 OIL B. C. ❑ 1e REGULAR UNLEADED ❑ 3 DIESEL ❑ 6 AVIATION GAS A. 1J[1 2 PETROLEUM ❑ g0 EMPTY ❑ 1 PRODUCT ❑ 1b PREMIUM UNLEADED ❑ 4 GASAHOL ❑ ] METHANOL /^-`l ❑ lc MIDGRADE UNLEADED 5 JET FUEL ❑ 6 MB5 ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑J 2 LEADED 99 OTHER(DESCRIBE INTEMD.BELO" D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED r n DE , C.A.S.M 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 �1 BARE STEEL E::] 2 STAINLESS STEEL E:] 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B. TANK MATERIAL ❑ 5 CONCRETE E:] 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 0 100% 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 100%METHANOL? YES— NOX D.EXTERIOR ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC CORROSION ❑95 UNKNOWN ❑ 99 OTHER PROTECTION ❑ 5 CATHODIC PROTECTION 91 NONE SPILL CONTAINMENT INSTALLED(NEAR) OVERFILL PREVENTION EOUIPMENTINSTALLED(YEAR) E.SPILL AND OVERFILL,BIC. DROPTUBE YES_ NO_ STRIKER PLATE VES_ NO_ DISPENSER CONTAINMENT YES NO IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION A 0 SINGLE WALL A U 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)A U 4 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL W/COATING A U a 100% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER 1 MECxA0'11 UNE LFAIt 2 UNE NGKTNESS 3 CCNnN S INTERMAL ❑4 ELECTRONIC UNE ❑5 AUf01MTt PUMP gg OTHER D. LEAK DETECTION ❑ oETEaoR ❑ r6snxG ❑ uaNrIMNG LMK DErECron SHLTUGVIN V.TANK LEAK DETECTION ❑ AUTOMA 1 VISUAL CHECK ❑ 2 RMANUAL ECO CIUATIONORY ❑ 3 MONITORING VADOZE ❑ 4 GAUGING MONITORING TANK ❑ 5 MONTORINGGROUND TER ❑6 TESTING ❑ 7 MONTORNG INTERSTITIAL ❑ B SIR ❑ 9 WEEKLY MAlr�lNUAL ❑10 MOri NTHLY TANK 95 UNKNOWN ❑ 99 OTHER TING VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE N-PUCE) 1.ESTIMATED DATE LAST USED(MO/OAY/YR) 2.ESTIMATED QUANTITY OF 3.WASTANK FILLED WITH YES ❑ NO ❑ SUBSTANCE REMAINING GALLONS IN ERT MATER,AL7 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&SIGNATURE) LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW 1 COUNTY# JURISDICTION# = FACILITY# STATE I.D:# PERMIT NUMBER PERMIT APPROVED BYIDATE PERMIT THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORMA HAS BEEN FILED. FORM C MUST BE COMPLETED FOR INSTALLATIONS. THIS FORM SHOULD BE ACCOMPANIED BY A PLOT PLe f E THIS FORM WITH THE LOCAL AGENCYIMP✓EMENTING THE GROUND STORAGE TANK REGULATIONS FORM B (6-95) 4 77 l.'Yn