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fr�OV aCl3 STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD s g UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY 0 1 NEW PERMIT a 3 RENEWAL PERMIT Q 5 CHANGE OF INFORMATION a 7 PERMANENTLY CLOSED ON SITE ONE ITEM F-� 2 INTERIM PERMIT 0 4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE 0 8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: l� I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A. OWNER'S TANK I.D.# "3; B. MANUFACTURED BY: r C. DATE INSTALLED(MO/DAYNEAR) D. TANK CAPACITY IN GALLONS: II,TANK CONTENTS IF A-1 IS MARKED,COMPLETE ITEM C. ,q. 1 MOTOR VEHICLE FUEL 4 OIL B. C LJ to REGULAR UNLEADED 0 3 DIESEL 0 6 AVIATION GAS 0 2 PETROLEUM 80 EMPTY 1PRODUCT 1b PREMIUM UNLEADED E�] 4 GASAHOL Ej 7 METHANOL 1c MIDGRADE UNLEADED 5 JET FUEL L] 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 O 1 DOUBLE WALL r--] 3 SINGLE WALL WITH EXTERIOR LINER 5 INTERNAL BLADDER SYSTEM Ej 95 UNKNOWN SYSTEM �2 SINGLE WALL O 4 SINGLE WALL IN A VAULT 99 OTHER B. TANK 1 BARE STEEL F-] 2 STAINLESS STEEL F7 3 FIBERGLASS 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL 5 CONCRETE 71 6 POLYVINYL CHLORIDE F--] 7 ALUMINUM a 8 100% METHANOL COMPATIBLE W/FRP (Primary Tank) E::] 9 BRONZE E:l 10 GALVANIZED STEEL a 95 UNKNOWN 0 99 OTHER C.INTERIOR 71 1 RUBBER LINED 2 ALKYD LINING a 3 EPDXY LINING E::] 4 PHENOLIC LINING LINING OR O 5 GLASS LINING 496 UNLINED 0 95 UNKNOWN F--1 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO— D.EXTERIOR 1 POLYETHYLENE WRAP O 2 COATING ❑ 3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC CORROSION PROTECTION E:] 5 CATHODIC PROTECTION [::] 91 NONE 95 UNKNOWN 99 OTHER E.SPILL AND OVERFILL,etc. SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) DROP TUBE YES NO STRIKER PLATE YES 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 Ad'C� PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION A SINGLE WALL A U 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)A U 4 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL W/COATING A U 8 100% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION UNKNOWN A U 99 OTHER D. LEAK DETECTION [:]1 MECHANICAL LINE LEAK O 2 LINE TIGHTNESS 3 CONTINUOUS INTERSTITIAL ❑4 ELECTRONIC UNE ❑5 AUTOMATIC PUMP a 99 OTHER DETECTOR TESTING MONITORING LEAK DETECTOR SHUTDOWN V.TANK LEAK DETECTION MANUAL INVENTOED 1 VISUAL CHECK RECONCILIATIONRY 3 MONIITORING VAOZE ❑ 4 GAUGING AUTOMATIC TANK 5 MON TORINGGROUND WATER ANNUAL 7 MONITORCONTINUOUS o 8 SIR 9 TANK WEEKLY MANUAL 0 10 MONTHLY TANK E-] 95 UNKNOWN 99 OTHER VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) 1.ESTIMATED DATE LAST USD O Y/YR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES NO 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 8 SIGNATURE) LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY# TANK# 3 STATE I.D.# K vi / 3 S 1 v PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATIO AT THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. FORM C MUST BE COMPLET D FOR INSTALLATIONS. THIS FORM SHOULD BE ACCOMPANIED BY A PLOT POLE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE Ut�ER GROUND STORAGE TANK REGULATIONS FORM B (6-95) � FOR0034B•R7 I