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• STATE OF CALIFORNIA • STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. `'��_�•" MARK ONLY Ell NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ ONE REM E] 2 INTERIM PERMIT 5 CHANGE OF INFORMATION ❑ ] PERMANENTLY CLOSED ON SITE ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE Ey 8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: I. TANK DESCRIPTION COMPLETE ALL ITEMS— SPECIFY IF UNKNOWN A OWNER'S TANK I.D.X Form T nk B. MANUFACTURED 8Y: C. DATE INSTALLED(MO/DAY/YEAR) UnknownD. TANK CAPACITY IN GALLONS: II.TANK CONTENTS IFA-1 IS MARKED,COMPLETE ITEM C. SSO A ❑ 1 MOTOR VEHICLE FUEL ❑ 4 OIL B C, ❑ 1a REGUUR UNLEADED ❑ 3 DIESEL ❑ fi AVIATION GAS ❑ 2 PETROLEUM ® 80 EMPry ❑ 1 PRODUCT ❑ 1b PREMIUM UNLEADED ❑ 4 GASAHOL ❑ T METHANOL ❑ 3 CHEMICALPRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ tc MIDGRAOE UNLUDED ❑ 5 JET FUEL ❑ 8 M85 ❑ 2 LEADED ❑ g8 OTHER(DESCRIBE IN REM D.BELOW) 0. IF(0.1)15 NOT MARKED, ENTER NAME OF SUBSTANCE STORED III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A,B,AND C,AND ALL THAT APPLIES IN BOX D AND E C.A S.#; A. TYPE OF ❑ 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ SYSTEM ❑ 5 INTERNAL BLADDER SYSTEM ❑ 95 UNKNOWN ® 2 SINGLE WALL d SINGLE WALL IN A VAULT ❑ 99 OTHER B. TANK ® 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ MATERIAL ❑ 5 CONCRETE 4 STEEL CLAD W1 FIBERGLASS REINFORCED PLASTIC ❑ 8 POLYVINYL CHLORIDE ❑ J ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP (PHRIaTY Tank) ❑ g BRONZE ❑ 10 GALVANIZED STEEL ❑ 85 UNKNOWN ❑ 99 OTHER C.INTERIOR ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY U LINING OR NING ❑ 4 PHENOLIC LINING ❑ 5 GLASS LINING ❑ 6 UNLINED ® 95 UNKNOWN COATING ❑ 99 OTHER IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO— D. CORROSION EXTERIOR ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ® 91 NONE 0 9 UNKNOWN ❑ 99 OTHER E.SPILL AND OVERFILL,eiC, SPILL CONTAINMENT INSTALLED(�'EqR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) DROP TUBE YES NO STRIKER PI YES_ NO_� IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND,BOTH IF APPLICABLE DISPENSERCONTAINMENT YES_ NO_ A. SYSTEM TYPE 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLEPIPING A U 99 OTHER B. CONSTRUCTION A 1 SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRE—'C'A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND A W i 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 PROTECTION U ] STEEL COATING A U B 1METHANOL COMPATIBLE W/FRP A U 9 GALVANIZED STEEL p U 10 CATHODIC PROTECTION A U 955 OTHER UNKNOWN A U 99 OTHER None D. LEAK DETECTION 1 WCION)M.UNE LEAK 2 UNE VGKRESS ❑3 CWNUOUS IN1ERSn11AL ❑4 ELECTRONIC UNE 5 AvownC IKIMn ❑ D-1EMM TE�� MONITORING LEAK GETECiOH ❑ V.TANK LEAK DETECTION sNMmO m ❑ es o HER 1 VISUAL ❑ 2 MANUAL INVENTORY 3 VADOZE MONIITORING ❑ 4 GAUGNGAUTOMATIC TANK E] 5 MONTORINGGROUND TER ❑ fi TANNUAL ESTING❑ 7 CONTINUOUS INTERSTITIALRECONCILIATION ❑ MONITORING ❑ 8 SIR ❑ 9 WEEKLY MANUAL ❑10 MONTHLY TANK TANKGAUGING TESTING ® 95 UNKNOWN ❑99 OTHER VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) 1.ESTIMATED DATE LAST USED(MO/DAYNR) 2.ESTIMATED QUANTITY OF Unknown SUBSTANCE REMAINING O GALL3.WAS TANK FILLED WITH YES ❑ NO ONS 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 (PRINTED 6 SIGNATURE) DATE 5/18/99 LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW CO�# JURISDICTION# r FACILITY 6/,�j / TA =NUMBER I. V PERMIT APPROVED BV/DATE PERMIT EXPIRATION DATE THIS FORM MUST BE ACCOMPANIED BY A PERMIT APP TION-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 FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING TH�DERGROUND STORAGE TANK REGULATIONS FORM B (6-95) r