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A L STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD e UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B I. : COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ® 1 NEW PERMIT ❑i 3 RENEWAL PERMIT ® 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ON SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ B TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: 1. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A OWNER'S TANK I.D.a 2 B. MANUFACTURED BY: Q eS C. DATE INSTALLED(MO/DAYNEAR) 4 97 0. TANK CAPACITY IN GALLONS: 1 v (� It.TANK CONTENTS IF A-1 IS MARKED,COMPLETE ITEM C. A N 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. :a REGL LAR UNLEADED -I 3 DIESEL 6 AVIATICNGAS 2 PETROLEUM 80 EMPTY t PRODUCT 15 PIEV.:iM UNLEADED 4 GASAHOL ❑ 7 METHANOL ❑ ❑ �i � tc M10GAADE UNLEADED 5 JET FUEL ❑ 8 M85 ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED �( 99 OTHER ICESCRIBE IN ITEM 0.5ELOY,j 0. 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.S.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 ❑I, 95 UNKNOWN n SYSTEM 2 SINGLE WALL ❑ 4 SINGLE WALL IN A VAULT L_. 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 ❑ 5 l00% 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 ® 8 UNLINED !1 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 4 FIBERGLASS REINFORCED PLASTIC CORROSION PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) E.SPILL AND OVERFILL,BSC. DROP TUBE YES__&C_ 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 CHL'OaIDE(PVC)AG/4 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL W/COATING A U B 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 1 MECKUNICAL UNE LEAK 2 UNE TI GMKESS 3 CCMI1.VOUS UlrRSTTTIAL 4 ELECTRCNIC URE 5 AUTOMATIC PUMP 99 OTHER ® DETECTOR ❑ TESTING MONTCf.INO ❑ LEAK C£TECWR X, SHUT,OV'.N ❑ V.TANK LEAK DETECTION 1 VISUAL CHECK ❑ 2 MANUAL RECONCILATIONORY F-13 MO I ORING - 4 AUTOMA7GAUGING IC TANK f 5 GROUND MONTORINGTER f❑— 6 ANNUALTEST'NGTANf ® 7 CONTINUOUS INTERSTITIAL ❑ S SIR ❑ 9 WEEKLY MANUAL ❑ 10 MONTHLY TANK J 95 UNKNOWN I 99 OTHER MONITORING TANK GAUGING TESTING'__ VL TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) 1.ESTIMATED DATE LAST USED(MOIDAYNR) I 2.ESTIMATED QUANTITY OF 3.NAS TANK FILLED WITH YES j❑ NO SUBSTANCE REMAINING GALLONS I INERT MATERIAL 7 THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OFAlY KNOWLEDGE, IS TRUE AND CORRECT TANK OWNER'S NAME DATE (� (PRINTED 6 SIGNATUREI �\1.—•� I, LOCAL AGENCY USE ONLY THE STATE`I.D.NUMBER IS COMPOSED OF THE FOUR 48ER. BELOW COUNTY# JURISDICTION a F CILITY+ TANK# STATE I.D.9 = = PERMIT NUMBER PERMIT APPROVED BYICATE i PERMIT EXPIRATION UATE THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORM A HAS BEEN F.U.D. 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 LNDERGROUND STORAGE TANK REGULATIONS FORM B (6-95)