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STATE OF CALIFORNIA ..""'.."' STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B i COMPLETE A SEPARATE FORM FOR EA H TANK SYSTEM. Q 9 MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT5 CHANGE OF INFORMATION Q 7 PERMANENTLY C ONE REM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE ❑ B TANK REMOVE DBA OR FACILITY NAME WHERE TANK IS INSTALLED: I. TANK DESCRIPTION COMPLETE ALL ITEMS– SPECIFY IF UNKNOWN A OWNER'S TANK I.D.Y 001 1 S. MANUFACTURED BY: C. DATE INSTALLED(MO/DAYNEAR) D. TANK CAPACITY IN GALLONS: II.TANK CONTENTS IF A-1 IS MARKED,COMPLETE ITEM C. A. 1 MOTOR VEHICLE FUEL 04 OIL S. C. E::] to REGULAR UNLEADED 3 DIESEL El e AVIATION GAS ❑ 2 PETROLEUM ❑ 80 EMPTY PRODUCT ❑ Z PREMNM UNLEADED ❑ 4 GASAHOL ❑ 7 METHANOL ❑ Ic MIDGMDE UNLEADED ❑ 5 JET FUEL ❑ B MB5 ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED Q 99 OTHER(DESCRIBE IN ITEM D.BELOW) D. IF(Al)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 ❑ OUBLE WALL F--13 SINGLE WALL WITH EXTERIOR LINER O 5 INTERNAL BLADDER SYSTEM ❑ 95 UNKNOWN SYSTEM GLE WALL ❑ 4 SINGLE WALL IN A VAULT ❑ 99 OTHER B. TANK 1 BARE STEEL O 2 STAINLESS STEEL O 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE O 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP (Primary Tmk) ❑ 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_ NO— D.EXTERIOR ❑ 1 POLYETHYLENE WRAP ❑ 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. SPILLCONTAINMENT 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 A U 1 SUCTION A )2 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION AlD 1 SINGLE WALL A U 2DOUBLE 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 7W/COATING A U 8 100% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 ALVANIZED STEEL A U 10 CATHODIC PROTECTION AV5 UNKNOWN A U 99 OTHER D. LEAK DETECTION MEC.Im UNE L ❑2 NNE TMWMSS 3 WNBNUWS IMEA9 4 1::14 ELEOTR01#L LINE O 5 AUTONAL c WIN O 99 OTHER OEiEmil Te5PN0 MOMTO IFAK OEIELTCf1 SHU10pWN V.TANK LEAK DETECTION 0 1 VISUAL CHECK ❑ 2 RECO CIUATIONANUAL ORY ❑ 3 MAODNIITORING 4 GAUGINGAUTOMATIC TANK ❑ 5 MONTORINGOZE GROUND TER F-16 TESNNGTANK ❑ 7 MON TNUOU INTERSTITIAL E:] 8 SIR ❑ 9 TANKLY MANUAL ❑ 10 MOTESTINGHLY TANK❑ 95 UNKNOWN ❑99 OTHER ANNUAL VI,TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) 1.ESTIMATED DATE LAST USED(MO/DAYNR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES ❑ NO ❑ SUBSTANCE REMAINING GALLONS INERT MATERIAL T 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 (PRNTED d SIGNATURES LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY# TANK# Q STATE I.D:# PERMIT NUMBER PERMIT APPROVED SYMATE PERMIT EXPIRATION DATE THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICI"014-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. F("--C MUST BE COMPLETED FOR INSTALLATIONS. THIS FORM SHOULD BE ACCOMPANIED BY A PLOT PL,%WS'ILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE RGROUND STORAGE TANK REGULATIONS FORM 8 (6.95) — �— Q F I,,�I-I 1