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%A. s STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD �� e UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B ( COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT O 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ONSITE ONE ITEM 2 INTERIM PERMIT O 4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE 0 8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: , S' 40 c I. TANK DESCRIPTION COMPLETE ALL ITEMS— SPECIFY IF UNKNOWN A OWNER'S TANK I.D.It B. MANUFACTURED BY: C. DATE INSTALLED(MO/DAY/YEAR) D. TANK CAPACITY IN GALLONS: ILTANK CONTENTS IFA-11S MARKED,COMPLETE ITEM C. A1 MOTOR VEHICLE FUEL O 4 OIL 8. C. ❑ Ia REGULAR UNLEADED �3 DIESEL ❑ 6 AVIATIONGAS x2 PETROLEUM O 80 EMPTY I PRODUCT C] 1b PREMIUM UNLEADED 4 GASAHOL E] 7 METHANOL ❑ 1c MIDGRADE UNLEADED ❑ 5 JET FUEL ❑ 8 M85 3 CHEMICALPRODUCT O 95 UNKNOWN ❑ 2 WASTE 2 LEADED D 99 OTHER(DESCRIBE IN REM 0.8ELOYQ D. IF(A1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A S.It: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A B.AND C.AND ALL THATAPPLIES IN BOX D AND E A. TYPE OF ❑ I DOUBLE WALL O 3 SINGLE WALL WITH EXTERIOR LINER ❑ s INTERNAL BLADDER SYSTEM ❑ 95 UNKNOWN SYSTEM 2 SINGLE WALL ❑ 4 SINGLE WALL IN A VAULT ❑ 99 OTHER 1 B. TANK /+�J.I BARE STEEL O 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL u 5 CONCRETE O 6 POLYVINYL CHLORIDE O 7 ALUMINUM O 8 100% METHANOL COMPATIBLE W/FRP (Primary Tank) 9 BRONZE O 10 GALVANIZED STEEL O 95 UNKNOWN O 99 OTHER C.INTERIOR ❑ I RUBBER LINED 0 2 ALKYD LINING 3 EPDXY LINING 4 PHENOLIC LINING LINING OR O 5 GLASS LINING 6 UNLINED 95 UNKNOWN ❑ 99 OTHER COATING IS LINING MATERIAL COMPAT WITH 10096 METHANOL? YES_ NO>< D.EXTERIOR ❑ I POLYETHYLENE WRAP O 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC CORROSION91 NONE ❑ 95 UNKNOWN 99 OTHER PROTECTION E] s cATHoolc PRorEcnoNiN SPILL CONTAINMENT STA U(YR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) DROP TUBE YES_ NO 5 KER PLATE YES_ NO DISPENSER CONTAINMEN E.SPILL AND OVERFILL,MC. YES .NO IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION A 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 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 1 YECWWICAL UNE LEAK 2 WE TNHTNE$ 3 LrxrtmYCG$INTERSTINl ❑4 ELEC IC UNE ❑5 AUTOIMRC WAP 99 OTHER op D. LEAK DETECTION ❑ DETECTOR ❑ TESTMG YONTORRKA LEM I)ETEOTOR SHGTOOWN V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK 2 MANUAL INVENTORY OO4 MAC TANK ❑ 6 TER�6 TETANKG STING ECONCILIATONMONITORING ❑ 7 MON TORONG INTERSTITIAL O B SIR ❑ 9 WEEKLY MANUAL E]10 MONTHLY TANK ❑ 95 UNKNOWN ❑ 99 OTHER NG 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 E]SUBSTANCEREMAINING GALLONS INERT MATERIAL? THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT DATE TANK OWNER'S NAME (PRINTED d SIGNATURE) LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW PIQ --0 111 q COUNTY If JURISDICTION# FACILITY# TANK If 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 FORMA HAS BEEN FILED. FORM C MUST BE COMPLETED FOR INSTALLATIONS.THIS FORM SHOULD BE ACCOMPANIED BY A PLOT PL"FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE,"---IRGROUND STORAGE TANK REGULATIONS +I FORMS 16.95) NOW