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�yov"ces STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD ;` g UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. c•` "� MARK ONLY 1 NEW PERMIT ❑ 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: ❑ 3 FIBERGLASS J;j�L 4 STEEL CLAD W/ FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE 1 TAKIIC nC0flt3ln r%kl _..... _.. ._.._ ____._.._....._'._."" ❑ 8 100% METHANOL COMPATIBLE W/FRP (PrimaryTank) ❑ 9 BRONZE A OWNER'S TANK 1. D. # g_ C ❑ 1a REGULAR UNLEADED ❑ 3 DIESEL 6 AVIATION GAS 2 PETROLEUM ❑ 80 EMPTY B. MANUFACTURED BY: 1:11h PREMIUM UNLEADED ❑ 4 GASAHOL 7 METHANOL ❑ is MIDGRADE UNLEADED ❑ 5 JET FUEL ❑ 8 M85 C. DATE INSTALLED (MO/DAYNEAR) J ❑ 2 WASTE LEADED ❑ 99 OTHER (DESCRIBE IN ITEM D. BELOIM1Q / D. TANK CAPACITY IN GALLONS: ❑ 3 FIBERGLASS IL TANK CONTENTS IF A-1 IS MARKED, COMPLETE ITEM C. A ® 1 MOTOR VEHICLE FUEL ❑ 4 OIL g_ C ❑ 1a REGULAR UNLEADED ❑ 3 DIESEL 6 AVIATION GAS 2 PETROLEUM ❑ 80 EMPTY 1 PRODUCT 1:11h PREMIUM UNLEADED ❑ 4 GASAHOL 7 METHANOL ❑ is MIDGRADE UNLEADED ❑ 5 JET FUEL ❑ 8 M85 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE LEADED ❑ 99 OTHER (DESCRIBE IN ITEM D. BELOIM1Q D. IF (AT) IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C. A S. sr 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 e2r� 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 J;j�L 4 STEEL CLAD W/ FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP (PrimaryTank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER C. INTERIOR ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLId LINING LININGOR ❑ 5 GLASS LINING , 44 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES _ NO— D. EXTERIOR ❑ i POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC CORROSION PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER E SPILL AND OVERFILL, BtC. SPILL CONTAINMENT INSTALLED (YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED (YEAR) �,' / DROP TUBE YES NO T IKER PLATE YES NO DISPENSER CONTAINMENT YE�— NO IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND, BOTH IF APPLICABLE A. SYSTEM TYPE A 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 (V2 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 4—tx FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL Wl 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 MECHANICAL LINE LEAK [:]TESTING 2 UNE TIGHTNESS 3 CONTINUOUS INTERSTITIAL4 ELECTRONIC LINE 5 AUTOMATIC PUMP ❑ ❑ ❑ 99 OTHER DETECTOR MONITORING LEAK DETECTOR SHUTDOWN V. TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 RECONCILIATIONORY ❑ 3 MONIITORING ❑ OZE 4 GAUGING AUTOMATIC TANK ❑ 5 GROUND MONITORING TEA ❑ 6 TTEESTINGTANK 7 CONTINUOUS INTERSTITIAL [:] 8 SIR ❑9 TK�G10 MONTHLY TANK 5 UNKNOWN ❑99 OTHER NAG❑MOTORNGTESTING VI. TANK CLOSURE INFORMATION (PERMANENT CLOSURE IN-PLACE) THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF OF MY KNOWLEDGE, IS TRUE AND CORRECT THE FOUR NUMBERS BELOW • IMIV(� M STATE I.D.4 m � I r_TT] 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 PLAN. FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS FORM B (695)