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STATE OF CALIFORNIA r STATE WATER RESOURCES CONTROL BOARD ; UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED O ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE 8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: L o q i 1,3 I. TANK DESCRIPTION COMPLETE ALL ITEMS– SPECIFY IF UNKNOWN A OWNER'S TANK I.D.N B. MANUFACTURED BY: C. DATE INSTALLED(MO/DAYNEAR) Z D. TANK CAPACITY IN GALLONS: 00 ]� II.TANK CONTENTS IF A-1 IS MARKED,COMPLETE ITEM C. 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C 1a REGULAR UNLEADED E] 3 DIESEL ❑ 6 AVIATION GAS A 1b PREMIUM UNLEADED ❑ 4 GASAHOL ❑ 7 METHANOL ❑ 2 PETROLEUM ❑ 80 EMPTY 1 PRODUCT 1c MIDGRADE UNLEADED ❑ 5 JET FUEL ❑ 8 M85 ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN 7777❑ 2 WASTE ❑ 2 LEADED ❑ 99 OTHER(DESCRIBE IN ITEM 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 E 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 W/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 �3 6 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 1000% METHANOL? YES_ NO— D.EXTERIOR ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC CORROSION PROTECTION ❑ 5 CATHODIC PROTECTION M 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER E.SPILL AND OVERFILL,BtC. 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 U 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` U 1 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 I MECHANICAL UNE LEAK 2 UNE TIGHTNESS ❑3 CONTINUOUS INTERSTITIAL ❑4 ELECTRONIC UNE O 5 AUTOMATIC PUMP DETECTOR TESTING MONITORING LEAK DETECTOR SHUTDOWN ❑ 99 OTHER V.TANK LEAK DETECTIONMANUAL �/ ❑ 2 RECONCILIATIONORY ❑ 3 MONIITORING ❑ 4 GA G NGIC TANK [:] 5 MON TORINGTER X 6 TESTINGTANK �1 VISUAL CHECKVAOZEGROUND ❑ 7 CONMON TI INTERSTITIAL ❑ 8 SIR ❑ 9 WEEK LY MANUAL ❑10 MONTHLY TANK ❑ 95 UNKNOWN 99 OTHER ORINTESTING VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) 1.ESTIMATED DATE LAST U.g57ED(MO/DAYNR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES E NO /' — ' - — CC/ '7 SUBSTANCE REMAINING GALLONS INERT MATERIAL? THIS FORM HAS BdEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT TANK OWNER'S NAME /� DATE (PRINTED 6 SIGNATUREI_� \� P LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR MBERS BELOW COUNTY# JURISDICTION# FACILITY# V7?3 TANK# D STATE I.D.# C' a 3 s 3 = PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DAT 7 Z 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) ^ _ � � ✓ ('j� (/L �