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STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD iyd� - + UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B _ , I COMPLETE A SEPARATE FORM FOR EA H TANK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT O 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CL SITE ONE REM ❑ 2 INTERIM PERMIT E] ERMIT 6 4 AMENDED PLTEMPOR.ARY TANK CLOSURE ❑ 8 TANK REMOVE DBA OR FACILITY NAME WHERE TANK IS INSTALLED: '7 I. TANK DESCRIPTION COMPLETE ALL ITEMS– SPECIFY IF UNKNOWN A OWNER'S TANK I.D.Y y B. MANUFACTURED BY: C. DATE INSTALLED(MOIDAYNEAR) D. TANK CAPACITY IN GALLONS: O 0� II.TANK CONTENTS IF A-1 IS MARKED,COMPLETE ITEM C. 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C. ❑ la REGULAR UNLEADED 3 DIESEL ❑ fi AVIATION GAS A ❑ 10 PREMNM UNLEADED 4 GASAHOL ❑ 7 METHANOL ❑ 2 PETROLEUM ❑ 80 EMPTY 1 PRODUCT ❑ le MIDGRADE UNLEADED ❑ 5 JET FUEL ❑ 8 M85 ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED ❑ 99 OTHER(DESCRIBE IN REM D.BELOW) D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S.p III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.S,AND C,AND ALL THAT APPLIES IN BOX D AND E A. TYPE OF ❑ OUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 5 INTERNAL BLADDER SYSTEM ❑ 95 UNKNOWN SYSTEM GLE WALL ❑ 4 SINGLE WALL IN A VAULT ❑ 99 OTHER B. TANK 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 (PTIIIIery Tank) ❑ 9 BRONZE O 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER C.INTERIOR ❑ 1 RUBBER UNED ❑ 2 ALKYD LINING ❑ 3 EPDXY UNING ❑ 4 PHENOUC LINING LINING OR ❑ 5 GLASS LINING ❑ e UNUNED ❑ 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 ❑ 91 NONE 95 UNKNOWN 99 OTHER 5 CATHODIC PROTECTION ❑ SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) E.SPILL AND OVERFILL,BIC. DROP TUBE YES_ NO_ STRIKERPLATE 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 Z 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 U 7 ST.Ef.IW1 COATING A U 8 100% METHANOL COMPATIBLE W/FRP PROTECTION A U 9ALVANIZED STEEL A U 10 CATHODIC PROTECTION Ao 5 UNKNOWN A U 99 OTHER MEGHANIGL UNE LEY! 2 LNE TGNTNE53 3 rlTW0U6 I14 R1 RAL 4 ELELTROWC UNE 5 AlROYARC PUMP 99 OTHER D. LEAK DETECTION rETEmoR ❑ TESTNo ❑ uowraRwc ❑ LEAx oErscron ❑ sNuroovm ❑ V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 RECONCILIIATIONORY ❑ 3 MONIITORING Lo�4 GAUGING AUTOMATIC TANK ❑5 GROUND MONITORING TESTING❑e ANNUAL TESTINGTANK ❑ 7 MONITOR U INTERSTITIAL ❑ 8 SIR E] 9 WEEKGAUGIN UAL [:]10 MOTHLY TANK ❑ 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 YES ED NO❑ SUBSTANCE REMAINING GALLONS INERT 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 (PRINTm ... SIGNATURE) LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY# � � TANK# � STATE I.D.# ® 111�9 I[a�! 7 PERMIT NUMBER PERMIT APPROVED BYIDATE PERMIT EXPIRATION DATE THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPUCXION-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 PLI 'ILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE �RGROUND STORAGE TANK REGULATIONS FORM B (6-95)