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A 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 ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE J DBA OR FACILITY NAME WHERE TANK IS INSTALLED: 4-b 1. , T I. TANK DESCRIPTION COMPLETE ALL ITEMS - SPECIFY IF UNKNOWN Pcy°unct5 C a� o ❑ 7 PERMANENTLY CLOSED ❑ 8 TANK REMOVED � f. A. OWNER'S TANK 1. D. #7 B. MANUFACTURED BY: J J`c��e C. DATE INSTALLED (MO/DAYNEAR) l D. TANK CAPACITY IN GALLONS: � II. TANK CONTENTS IF A-1 IS MARKED, COMPLETE ITEM C. A 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C ❑ 1a REGULAR UNLEADED ❑ 3 DIESEL ❑ 6 AVIATION GAS 1 PETROLEUM E] BO EMPTY ,< `1 PRODUCT 1b PREMIUM UNLEADED E]4 GASAHOL E]7 METHANOL is MIDGRADE UNLEADED ❑ 5 JET FUEL ❑ 8 M85 ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 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. #: 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 F—]3 SINGLE WALL WITH EXTERIOR LINER ❑ 5 INTERNAL BLADDER SYSTEM E]95 UNKNOWN SYSTEM 2 SINGLE WALL ❑ 4 SINGLE WALL IN A VAULT/ ❑ 99 OTHER B. TANK ❑ 1 BARE STEEL ❑ 2 STAINLESS STEEL 17� 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 F❑U 6 UNLINED ❑ 95 UNKNOWN F-199 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES NO N A U D. EXTERIOR ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP4 FIBERGLASS REINFORCED PLASTIC CORROSION PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER E. SPILL AND OVERFILL, etc. SPILL CONTAINMENT INSTALLED (YEAR) f OVERFILL PREVENTION EQUIPMENT INSTALLED (YEAR) ❑ DROP TUBE YES NO STRIKER PLATE YES NO DISPENSER CONTAINMENT YESy 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 AU 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) 6.:J 4 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEELW/COATING A U 8 100% METHANOL COMPATIBLEW/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION ❑ 1 MECHANICAL UNE LEAK ❑ 2 UNE TIGHTNESS 3 CONTINUOUS INTERSTITIAL 4 ELECTRONIC LINE ❑ 5 AUTOMATIC PUMP ❑ 99 OTHER DETECTOR TESTING MONITORING LEAK DETECTOR SHUTDOWN V. TANK LEAK DETECTION �❑j 1 VISUAL CHECK ❑ 2 MANUAL RECONCILIATION MONITORING ❑ 3 VADOZE MONIITORING ❑ 4 AUTOMATGAUGING MONITORING TANK ❑ 5 GROUND MONITORINGTER 6 ANNUALTESTING 1� 7 MONITORING CONTINUOUSINTERSTITIAL ❑ 8 SIR ❑ 9 TANK -GAUGING GAUGANGAL ❑ 10 MONTHLY TANK ❑ g5 UNKNOWN ❑ 99 OTHER VI. TANK CLOSURE INFORMATION (PERMANENT CLOSURE IN-PLACE) 1. ESTIMATED DAT LAUSED (MO/DAY/YR) 2. ESTIMATED QUANTITY OF 3. WAS TANK FILLED WITH YES ❑ NO ❑ 44 SUBSTANCE REMAINING GALLONS 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 NAME DATE (PRINTED b SIGNATURE) LOCAL AGENCY USE ONLY THE STATE I.D. NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY # JURISDICTION # FACILITY # I TANK #� STATE 04a 3 (� r 3 PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE 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 PI °ILE THIS FORM WITH THE LOCAL AGENCY YIIMPLEMENTING THE I mnERGROUND STORAGE TANK REGULATIONS �i�I FORM B (6-95)