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STATE OF CALIFORNIA A STATE WATER RESOURCES CONTROL BOARD .. m o UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. I � D 9 MARK ONLY F-1 1 NEW PERMIT a 3 RENEWAL PERMIT5 CHANGE OF INFORMATION O 7 PERMANENTLY CLO SITE / ONE REM r-] 2 INTERIM PERMIT O 4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE O 8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: I II JJ 1. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A OWNER'S TANK I.D.# B. MANUFACTURED BY: C. DATE INSTALLED(MOIDAYNEAR) D. TANK CAPACITY IN GALLONS: Q II.TANK CONTENTS IF A-1 IS MARKED.COMPLETE ITEM C. A 1 MOTOR VEHICLE FUEL 0 4 OIL B. C. 1a REGULAR UNLEADED 3 DIESEL 6 AVIATION GAS 2 PETROLEUM O 80 EMPTY <PROOUCT E] 10 PREMIUM UNLEADED O 4 GASAHOL O 7 METHANOL a 1c MIDGRADE UNLEADED O 5 JET FUEL 8 M85 3 CHEMICAL PRODUCT O 95 UNKNOWN 2 WASTE O 2 LEADED O 99 OTHER(DESCRIBE IN REM D.BELOW) D. IF(A1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S.M III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A,B.AND C,AND ALL THAT APPLIES IN BOX 0 AND E A. TYPE OF a1 UBLE WALL O 3 SINGLE WALL WITH EXTERIOR LINER O 5 INTERNAL BLADDER SYSTEM [-] 95 UNKNOWN SYSTEM 2 SI GLE WALL Q 4 SINGLE WALL IN A VAULT 99 OTHER B. TANK 1 BARE STEEL O 2 STAINLESS STEEL O 3 FIBERGLASS O 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL O 5 CONCRETE O 6 POLYVINYL CHLORIDE a 7 ALUMINUM a 8 100% METHANOL COMPATIBLE W/FRP (PHmary Tank) O 9 BRONZE O 10 GALVANIZED STEEL a 95 UNKNOWN O 99 OTHER C.INTERIOR O 1 RUBBER LINED O 2 ALKYD LINING O 3 EP LINING 4 PHENOLIC LINING LINING OR O 5 GLASS LINING 6 UNLINED95 UNKNOWN E:1 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES— NO— D.EXTERIOR O 1 POLYETHYLENE WRAP O 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC CORROSION PROTECTION 5 CATHODIC PROTECTION O 91 NONE - UNKNOWN O 99 OTHER E SPILL AND OVERFILL,CIC. 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 An SINGLE WALL A 0 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 STEEL W/COATING A U 8 100% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A 5 UNKNOWN A U 99 OTHER D. LEAK DETECTION 1 MECNAMCAL UNE UE 2 ME RGNMESS3 WIJWS INTERSM4 4 ELECTRONIC UME 5 MROW=MW 99 OTHER DETECTOR TESTING O C MONTORNG UAK OETEC W SMROOWN V.TANK LEAK DETECTION O 1 VISUAL CHECK O 2 MANUAL RECO CIUATIONORY O 3 MO�NOITORING 4 GAUGING AUTOMATIC TANK O 5 GROUND MONITORING O 6 ANNUAL TESTINGTANK O 7 MON INUOU INTERSTITIAL O 8 SIR ❑ 9 WEEKLY MANUAL O 10 MONTINGTHLY 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 O NO SUBSTANCE REMAINING GALLONS INERT MATERIAL 7 THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT (TXKTANK OWNER'S NAME DATE .O861GNAT N LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOWn COUNTY# JURISDICTION# FACILITY# -f ( TANK# a-+ STATE I.D:# ® 2 (W 'Sa'1 97 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. FOWL C MUST BE COMPLETED FOR INSTALLATIONS. THIS FORM SHOULD BE ACCOMPANIED BY A PLOT PL -ILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE RGROUND STORAGE TANK REGULATIONS FORM B (6-95) 1� �- / f 9 '41011, ' 'f -( n / u /