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STATE OF CALIFORNIA V.�ea STATE WATER RESOURCES CONTROL BOARD ;y'�� c i' UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B �� <o 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 ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: �jGjy I. TANK DESCRIPTION COMPLETE ALL ITEMS– SPECIFY IF UNKNOWN A OWNER'S TANK I.D.# ED BY: K' C. DATE INSTALLED(MODAYNEAR) D. TANK CAPACITY IN GALLONS: II,TANK CONTENTS IF A-1 IS MARKED,COMPLETE ITEM C. A, MOTOR VEHICLE FUEL ❑ 4 OIL B. C. REGULAR UNLEADED ❑ 3 DIESEL ❑ 6 AVIATION GAS 2 PETROLEUM E] 80 EMPTY 1 PRODUCT iG PREMIUM UNLEADED ❑ 4 GASAHOL ❑ 7 METHANOL ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN 2 y./ASTE ❑ lc MIDGRADE UNLEADED ❑ 5 JET FUEL ❑ 8 M85 ❑ 2 LEADED ❑ 99 OTHER(DESOMBEIN REM D.BELOW) D. IF(A.1)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 A. TYPE OF ❑ 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 5 INTERNAL BLADDER SYSTEM ❑ 95 UNKNOWN SYSTEM 2 SINGLE WALL ❑ 4 SINGLE WALL IN A VAULT ❑ 99 OTHER B. TANK 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD WI FIBERGLASS REINFORCED PLASTIC MATERIAL 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP (Primary Tank) ❑ 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 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER COATING IS LINING MATERIAL COMPATIBLE W/ITH 100°1. METHANOL? YES_ NO— D.EXTERIOR ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC CORROSION PROTECTION ❑ 5 CATHODICPROTECTION pit9l NONE ❑ 95 UNKNOWN ❑ 99 OTHER E.SPILL AND OVERFILL,Bic. 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 A U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION A&I SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND A 671 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 STEEL W/COATING A U 8 100% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION [:] NAMCAL 1 MECUNE LEAK 2 UNE 3 CONTINUOUS IMERETITAL 4 MUM00C UNE ❑5 AWOMATIC PUMP GETEOroR ❑ TIGIRNESS TESn6O MOWMING ❑ LE+x DETECTOR SHUTDOWN ❑ 99 orHER .,v V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 MANUAL ANNUAL ECONCILATIONINVENTORY ❑ 3 VAEMONITORING ❑ 4 GAUGNGAUTOMATIC TANK E] 6 MONITORINGGROUND ❑8 TESTINGTANK ❑ 7 CONTINUOUS MON TOR NG INTERSTITIAL ❑ 6 SIR ❑ 9 WEEKLY MANUAL ❑10 MONTHLY TANK ❑ 95 UNKNOWN ❑ 99 OTHER TANK GAUGING TESTING VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) 1.ESTIMATED DATE LAS USE (MOAOAY/YR) 2.ESTIMATED QUANTITY OF �N 3.WAS TANK FILLED WITH YES ❑ NO❑ SUBSTANCE REMAINING K./ 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 d SIGNATURE) LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW STATE LD:# COUNTY# JURISDICTION# FACILITY# TANK If ��J m [51C) 15Z-1711ZlA „ 7 PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE f/ 9 THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLI ON-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 PILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THIWRGROUND STORAGE TANK REGULATIONS FORM B (6-95)