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STATE OF CALIFORNIA `sem STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B COMPLETE A SEPARATE FORM FOR!2 TANK SYSTEM. MARK ONLY F-1 1 NEW PERMIT O 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION O 7 PERMANENTLY CLO SITE ONE REM 2 INTERIM PERMIT O 4 AMENDED PERMITO 6 TEMPORARY TANK CLOSURE 8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: L _ - I. TANK DESCRIPTION COMPLETE ALL ITEMS— SPECIFY IF UNKNOWN A OWNER'S TANK I.D.N B. MANUFACTURED BY: C. DATE INSTALLED(MO/DAYNEAR) 19 D. TANK CAPACITY IN GALLONS: Q II.TANK C NTENTS IF A-1 IS MARKED,COMPLETE ITEM C. p 1 MOTOR VEHICLE FUEL 4 OIL B. C. El 18 REGULAR UNLEADED 3 DIESEL O 6 AVIATION GAS O 2 PETROLEUM O 80 EMPTY PRODUCT O 1b PREMIUM UNLEADED O 4 GASAHOL � 7 METHANOL 1c MIDGRADE UNLEADED O 5 JET FUEL O B M85 0 3 CHEMICAL PRODUCT O 95 UNKNOWN 2 WASTE Ej 2 LEADED O 99 OT11ER(DESCRIBEINfTEMD.BELOYl) D. IF(A1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S.N 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 UBLE WALL O 3 SINGLE WALL WITH EXTERIOR UNER 5 INTERNAL BLADDER SYSTEM 0 95 UNKNOWN SYSTEM �GLE WALL Q 4 SINGLE WALL IN A VAULT O 99 OTHER B. TANK Tf-i BARE STEEL O 2 STAINLESS STEEL 0 3 FIBERGLASS E:] 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC 'I MATERIAL 5 CONCRETE O 6 POLYVINYL CHLORIDE 7 ALUMINUM 8 10M METHANOL COMPATIBLE W/FRP (PHIR#ry Te k) O 9 BRONZE O 10 GALVANIZED STEEL 95 UNKNOWN O 99 OTHER C.INTERIOR F__j 1 RUBBER LINED O 2 ALKYD LINING O 3 EP LINING 4 PHENOLIC LINING LINING OR ❑ 5 GLASS LINING Q 6 UNLINED 95 UNKNOWN ❑ 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 10TH METHANOL? YES— NO— D.EXTERIOR ❑ 1 POLYETHYLENE WRAP O 2 COATING O 3 VINYL WRAP E] 4 FIBERGLASS REINFORCED PLASTIC CORROSION PROTECTION ED 5 CATHODIC PROTECTION E:l 91 NONE a UNKNOWN O 99 OTHER E.SPILL AND OVERFILL,ElC. SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) DROP TUBE YES_ NO STRIKERPLATE YES NO_ DISPENSER CONTAINMENT YES NO IV.PIPING INFORMATION CIRCLE AIFABOVEGROUND ORUIFUNDERGROUND,BOTH IFAPPLICABLE A. SYSTEM TYPE U - SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION U ;1 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 U7 STE L W/COATING A U 8 10M METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODICPROTECTION U 5 UNKNOWN A U 99 OTHER D. LEAK DETECTION 1 MEcNW UNE LEAN Q 2 UNE TIGHTNESS O 3 COMINUWS IWE MAL O 4 ELECIRgNC LINE O 5 M01MTIG WAP O 99 OTHER DETECTOR TESTING WWMING LFAK OETE m SINITWLNN V.TANK LEAK DETECTION O 1 VISUAL CHECK O 2 RECONCILIATIONNUAL RY F] 3 MONIITORING OZE 4 GAUGING MONITORING AUTOMATIC TANK O 5 GROUND MONITORINGWATER O TANK 6 TESTING 7 MONITORCONTINUOUS � B SIR E:] 9 WEEKLY LY MANUAL O 10 MOTESTINGHLY TANK O 95 UNKNOWN 99 OTHER 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 SUBSTANCE REMAINING GALLONS INERT MATERIAL? YES O NO 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 (PPINTED451GNATURET LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY# TANK N STATE I.Dl S ® V-✓1 PERMIT NUMBER PERMIT APPROVED BYIDATE PERMIT EXPIRATION DATE 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 P! 9LE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE ERGROUND STORAGE TANK REGULATIONS FORMS (6-95) '�we �1