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40 STATE OFCAUFORNIA .�•`yo"�•.'�i STATE WATER RESOURCES CONTROL BOARD o UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B m COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ON SITE ONE REM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT g❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: vci 7 I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A OWNER'S TANK I.D.# j B. MANUFACTURED BY: C. DATE INSTALLED(MO/DAY/YEAR) D. TANK CAPACITY IN GALLONS: II.TANK CONTENTS IFA-1 IS MARKED,COMPLETE ITEM C. A ❑ 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C. 1a REGULAR UNLEADED ❑ 3 DIESEL ❑ 6 AVIATION GAS ❑ 2 PETROLEUM ❑ 80 EMPTV ❑ 1 PRODUCT ❑ 1b PREMIUM UNLEADED ❑ 4 GASAHOL ❑ 7 METHANOL ❑ 3 CHEMICALPRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADEAIDGRAD UNLEADED ❑ 5 JET FUEL ❑ B EMD ❑ 2 LEADED ❑ 99 OTHER(DESCRIBE IN REM D.BELOW) D. IF(A.1)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 ❑ 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER E:] 5 INTERNAL BLADDER SYSTEM E] 95 UNKNOWN SYSTEM ❑ 2 SINGLE WALL ❑ 4 SI E WALL IN A VAULT ❑ 99 OTHER B. TANK ❑ 1 BARE STEEL ❑ 2 INLES EL 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ PO WIN: HLORIDE 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE WIFRP (PHmery Tank) ❑ g BRONZE 10 GA ANI DST ❑ 95 UNKNOWN ❑ 99 OTHER C.INTERIOR ❑ 1 RUBBER U ED ❑ 2 ALKY LINING 3 EPDXY UNING ❑ 4 PHENOLIC LINING LINING OR F-15 GLASS UNIN ❑ 6 UNUNE 95 UNKNOWN ❑ 99 OTHER COATING IS LINING MATERIAL CO PATIBLE WITH 10D% METHANOL? Y S— NO— D.EXTERIOR ❑ 1 POLYETHYLENE W2 COATING 3 WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC CORROSION TI N PROTECTION ❑ 5 CATHODIC PROTEC91 ONE 95 UNKNOWN ❑ 99 OTHER E.SPILL AND OVERFILL,6I0. SPILL CONTAINMEN N ALL (YEAR) VERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) DROP TUBE YES S IKER PLATE WS NO_ DISPENSER CONTAINMENT YES_ NO IV. PIPING INATION CIRCLE A IF OVE ROUND 04 UN ERGROUND,BOTH IF APPLICABLE A. SYST TYPE A 1 SU T N 2 RESSU! A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER B. CON CTION A U 1 IN WALL A U\2 UBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL NO A U 1 TEEAA A U ST INLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A U 4 FIBERGLASS PIPE CORROSIO A U 5 A IN U 6C RETE A U 7 STEELW/COATING A U 8 100% METHANOL COMPATIBLE WIFRP PROTECTION A U 9 LVANIZEDA U 10\CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTI 1 MEC CAL UNE LEAK 2 NE nGNME55 3 CONfIN000S INTE0.5nnAL 4 ELFC111piIC UNE 5 AUfOAUnC PUAW ❑ D OR ❑ N'G ❑ MOMTORING ❑ LFAK O GTOR ❑ muTDOM ❑ 99 OTHER V.TANK LEAK DE ECTIO ❑ 1 VISUAL CHECK ❑ 2 MANUAL RECONCILIATION ❑ 3 VADOZE MONITORING ❑ 4 GAUGING AUTOMATIC TANK ❑5 GROUND MONITORING TER ❑ 6 TESTING ❑ 7 MON CONTINUOUS � STITIAL ❑ B SIR ❑ 9 TANK LY MANUAL ❑10 T MONTHLY TANK ❑ 95 UNKNOWN ❑ 99 OTHER 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? 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 8 SIGNATURE) LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY# TANK# STATE I.D:# m PERMIT NUMBER PERMIT APPROVED BY/DATE 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 pAgC�CCOOM;,PANIED BY,�A,PLOT PLA LE THIS FORM WIILT(H/THE �LOCAL AGENCY IMPLEMENTING THE GGRO7UND STIRAGE TANK REGULATIONS FORM E (6.85) D'O+W W 'I_�I"V V 1`/"' `� � "�'�. ' 'K ._ _®, , /7AYL wl { lS '�1'�Y7D_/j'`/'`�'1!_'j/TV(]/rLs �" Tr ll,{l.