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STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B Id: COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ® 1 NEW PERMIT C; 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: I. TANK DESCRIPTION COMPLETE ALL ITEMS— SPECIFY IF UNKNOWN A. OWNER'S TANK I.D.11 3 B. MANUFACTURED BY: \i Qkt Q.S C. DATE INSTALLED(MO/DAYNEAR) 1, �. O�'� ( D. TANK CAPACITY IN GALLONS: —\ C) 000 II.TANK CONTENTS IF A-1 IS MARKED,COMPLETE ITEM C. A. 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. i C. •a REGULAR UNLEADED 3 DIESEL 6 AVIATION GAS j❑ 2 PETROLEUM BO EMPTY1 PRODUCT 15 PREWUM UNLEADED 4 GASAHOL ❑ 7 METHANOL❑ i J is M;DGRADE UNLEADED 5 JET FUEL ❑ 84185 ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN 2 WASTE ❑ 2 LEADED 99 OTHER(CESCRIBE IV ITEI.1 D.5ELO;� 0. IF(A.1)IS NOT MARKED. ENTER NAME OF SUBSTANCE STORED C.A.S.m: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.B.AND C.AND ALL THAT APPLIES 1N BOX D AND E A. TYPE OF ® I DOUBLE WALL ❑j 3 SINGLE WALL WITH EXTERIOR UNER ❑ 5 INTERNAL BLADDER SYSTEM ❑ 95 UNKNO'.VN SYSTEM ❑ 2 SINGLE WALL ❑ 4 SINGLE WALL IN A VAULT ❑ 99 OTHER B. TANK ❑ I BARE STEEL 2 STAINLESS STEEL 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 iro% METHANOL COMPATIBLE WIFRP (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL L I 95 UNKNOWN ❑ 99 OTHER C.INTERIOR ❑ 1 RUBBER UNED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING C 4 PHENOLIC LINING LINING OR ❑ 5 GLASS LINING ® 6 UNLINED 95 UNKNOWN ❑ 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL 7 YES X— NO— D.EXTERIOR ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP �j 4 FIBERGLASS REINFORCED PLASTIC CORROSION PROTECTION ❑ 5 CATHOOICPROTECTION ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER E.SPILL AND OVERFILL,etc. SPILL CONTAINMENT INSTALLED(YEAR) OVERFILLPREVENTION EQUIPMENT INSTALLED(YEAR) DROP TUBE YES--X-- NO STRIKER PLATE YES X 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 U 1 SINGLE WALL A 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)ACUD 4 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEELW/COATING A U B 100% METHANOL COMPATIBLEWFRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER I MECWWICAL UNE LEAK 2 UNE llaWNM 3 CCNNh1JOUS INTERSTMAL 4 ELECTRONIC UNE 5 AUTOMATIC PUMP D. LEAK DETECTION ® CETECTOR ❑ TESnNa (�I MC+ATCRING ❑ LEAK CSTECTOA X= SHUTDOWN ❑ 99 OTHER V.TANK LEAK DETECTION 2 MANUAL INVENTORY 3 VADOZE 4 F7 1 VISUAL CHECK ❑ —I AUTOMATIC TANK (� 5 GRCUND WATER F-16 ANNUALTANK RECONCILIATION ❑ MONITORING J GAUGING MONITORING TESTING ® 7 CINUOMONITORING INTERSTITIAL ❑ a SIR ❑ 9 TAVEKGAUGINUAL I❑ 10 MONTHLY TANK ❑ 95 UNKNOWN 99 OTHER VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) 1.ESTIMATED DATE LAST USED(MO/DAYNR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES ❑ NO I SUBSTANCE REMAINING GALLONS I INERT MATERIAL 7 THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUEAND CORRECT TANK OWNER'S NAME DATE (� (PRINTED d SIGNATURE) LOCAL AGENCY USE ONLY \THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR N KERS ELOW COUNTY k JURISDICTION t1 FA LITY 1 TANK)r STATE 04 PERMIT NUMBER PERMIT APPROVED BY2IATE I PERMIT EXPIRATION DATE THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORMA,UNLESS A CURRENT FORMA 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)