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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 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 ❑ 6 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: RCA �Ca�'C 1 1. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A OWNER'S TANK I.D.e 3 B. MANUFACTURED BY: �es C. DATE INSTALLED(MOIDAYlYEAR) D. TANK CAPACITY IN GALLONS: O C)QU IL TANK CONTENTS IF A-1 IS MARKED,COMPLETE ITEM C. C.❑ 4 OIL i B. :a REGULAR UNLEADED ❑ 3 DIESEL ❑ 6 AVIATICN GA$ j ©A, X� 1 MOTOR VEHICLE FUEL17 PREN.:U%A UNLEACED ❑ 4 GASAHOL ❑ 7 METHANOL 2 PETROLEUM ❑ 60 EMPTY i 1 PRODUCT ❑ 1c WOGRADE UNLEADED C, 5 JET FUEL ❑ 8 5165 ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN J 2 WASTE ❑ 2 LEADED ❑ 99 OTHER;CESCRIBE IN ITEM D.5EL0'lll 0. IF(A.1)IS NOT MARKED. ENTER NAME OF SUBSTANCE STORED C.A.S. + 111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.S.AND C,AND ALL THAT APPLIES IN BOX D AND E A. TYPE OF ® 1 DOUBLE WALL ❑j 3 SINGLE MALL WITH EXTERIOR LINER �❑ 5 INTERNAL BLADDER SYSTEM ❑ 95 UNKNO'-'JN SYSTEM ❑ 2 SINGLE WALL ❑ 4 SINGLE WALL IN A VAULT i _1 99 OTHER B. TANK ❑ 1 BARE STEEL a 2 STAINLESS STEEL 3 FIBERGLASS ❑ 4 STEEL CLAD Wl FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE a 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 1G0% METHANOL COMPATIBLE WlFRP (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ` 1 95 UNKNOWN ❑ 99 OTHER C.INTERIOR ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING LINING OR ❑ 5 GLASS LINING 6 UNLINED J 95 UNKNOWN ❑ 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_X- NO_ 0.EXTERIOR 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ; 4 FIBERGLASS REINFORCED PLASTIC CORROSION u PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL REVENTION EQUIPMENT INSTALLED(YEAR) DROP TUBE YES X _ NO STRIKER PLATE YES X N'0 DISPENSER CONTAINMENT YES E.SPILL AND OVERFILL,etc. 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 I BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)ACU_f 4 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 6 CCNCRFI E A U 7 STEEL WI 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 MECHANICAL UNE LEAK 2 URE TIO}fTNE55 3 CCNnI.'000S ufT::RST7TIAL 4 ELEC�CNIC J.vE 5 AUTOMATIC PUMP I—1 g9 OT}IER D. LEAK DETECTION ® OE7ECOR rEsnNG 0 M04TORANG �J L"Jx C�'S_TOR s urro+nf l_ V.TANK LEAK DETECTION 1 VISUAL CHECK ❑ 2 MANUAL INVENTORY ❑ 3 MONITORINGJ 4 AUTOGAUGE MGIC TANK 5 ti3ONITORINGACUND WATER E 6 TESTING TANK RECONCILIATION 7 CONTINUOUS INTERSTITIAL ❑ 8 SIR ❑ 9 WEEKLY MANUAL ❑ 10 MONTHLY TANK ❑ 95 UNKNOWN 71 99 OTHER MONITORING TANK GAUGING TESTING VI,TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-?LACE) 1.ESTIMATED DATE LAST USED(MOIDAYNR) ! 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES '= NO SUBSTANCE REMAINING GALLONS I 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 NAMED DATE (PRINTED d SIGNATURE) LOCAL AGENCY USE ONLY THE STATE`I.D.NUMBER IS COMPOSED OF THE FOUR N BERS FLOW COUNTY# JURISDICTION# FA LIT`(# TANK# STATE I.D.# PERMIT NUMBER I PERMIT APPROVED BYTOATE PERMIT EXPIRATION DATE I 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 FCRM B (6.95)