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• ~' STATE OF CALIFORNIA `f *� STATE WATER RESOURCES CONTROL BOARD x��, e e UNDERGROUND STORAGE TANK PERMIT APPLICATION-FORM B >p - � o I COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ T PERMANENTLY CLOSED ONSITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: .S . ci I. TANK DESCRIPTION COMPLETE ALL ITEMS– SPECIFY IF UNKNOWN A OWNERS TANK I.D.# O r B. MANUFACTURED BY: C. DATE INSTALLED(MO/DAYNEAR) D. TANK CAPACITY IN GALLONS: It.TANK , CONTENTS IFA-1 IS MARKED,COMPLETE ITEM C. p JAI 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C.C. 1a REGULAR UNLEADED 3 DIESEL ❑ 6 AVIATION GAS F❑1 2 PETROLEUM ❑ 80 EMPTY ISI 1 PRODUCT ❑ 1b PREMIUM UNIEADFD 4 GASAHOI ❑ ] METHANOL //��\ ❑ Ic MIDGRADE UNLEADED O 5 JET FUEL ❑ 8 M85 ❑ 3 CHEMICALPRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED ❑ 99 OTHER(DESCRIBEIN REM D.BELOW) D. IF(A.1)ISNOTMARKED, ENTER NAME OFSUBSTANCE 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 ❑ I 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 O 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL O 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ ] ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP (Primary Twk) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER C.INTERIOR ❑ I RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING LINING OR ❑ 5 GLASS LINING 8 UNLINED [:] 95 UNKNOWN 99 OTHER COATING IS LINING MATERIAL COMPAT1 lE WITH 100% METHANOL? VES— NOX 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,BB:. SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENT) N OUIPMENT INSTALLED(NEAR) 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 A40 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION A C2 1 SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND A 1 BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A U 4 FIBERGLASS PIPE CORROSION A 5 ALUMINUM A U 6 CONCRETE A U ] 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 B9 OTHER D. LEAK DETECTION 1 MECNAMCAL IME IFIL( 2 INE TIGWNE 3 G IJWS INTERSTMAL 4 EIECMMIC IME 5 AUTOWTIC PUMP ❑ OETECfon ❑ TESTING MONTORMG LEAK DETECTOR ❑ SHUTOOmI 99 OTHER V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK 2 RECONCILMANUAL IATION MONITORING ❑ 3 VADOZE MONITORING ❑ 4 AUTOMATGAUGING MONITORING TANK ❑ 5 GROUND MONITORINGTER a ANNUALTESTING ❑ ] MON TOR U INTERSTITIAL ❑ B SIR ❑ 9 TANK LY MANUAL ❑10 MOTESTINGHLY TANK E] 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) 1.ESTIMATED DATE LAST USED(MO/DAY/YR) 2.ESTIMATED OUANTITY 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 OWNERS NAME DATE (PRIMED d SIGNATURE) LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW pp ;131119 COUNTY# JURISDICTION# FACILITY# TANK# STATE I.D.# 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 ACCOMPANIED BY A PLOT PLAN. FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS FORM B (6-95)