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• • t9pURC tS STATE OF CALIFORNIA Ar pO STATE WATER RESOURCES CONTROL BOARD , °o UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B s , o •O�t.F01.N� COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 16 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: Q V 1(C 5(O P I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN ,�/✓l/�e�1�,� A OWNER'S TANK I.D.# I,2--f2- B. MANUFACTURED BY: C. DATE INSTALLED(MO/DAYNEAR) I T E357 D. TANK CAPACITY IN GALLONS: OOD 1�1J1 II.TANK ONTENTS IF A-1 IS MARKED,COMPLETE ITEM C. A. 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C. ❑ 1a REGULAR UNLEADED ❑ 3 DIESEL a 6 AVIATION GAS ❑ 2 PETROLEUM ❑ 80 EMPTY I PRODUCT ❑ PREMIUM UNLEADED ❑ 4 GASAHOL ❑ 7 METHANOL 1c 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,8,AND C,AND ALL THAT APPLIES IN BOX D AND E A. TYPE OF 1 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 ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLEW/FRP (Primary Tank) ❑ g BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER C.INTERIOR ❑ 1 RUBBER LINED ❑ ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING LINING OR F-] 5 GLASS LINING U 6 UNLINED ❑ 95 y1JKNOWN ❑ 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO— D.EXTERIOR ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP E!f4 FIBERGLASS REINFORCED PLASTIC CORROSION ❑ PROTECTION 5 CATHODIC PROTECTION 91 NONE ❑ 95 UNKNOWN ED99 OTHER E.SPILL AND OVERFILL,etc. SPILL CONTAINMENT I TALLIED(YEAR) OVERFIL P VENTION 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 A 02 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL A g2 DOUBLE WALL A U 3 LINED TRENCH A 5 UNKNOWN A U 99 OTHER C. MATERIAL AND U 1 BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A U 4 FIBERGLASS PIPE CORROSION A'-T 5 ALUMINUM A U 6 CONCRETE A U 7 ST L W/COATING A U 8 100% METHANOL COMPATIBLE W/FRP PROTECTION A U/9 GALVANIZED STEEL/A U 10 CATHODIC PROTECTION 5 UNKNOWN A U 99 OTHER 1 MECHANICAL LINE LEAK 2 LINE TIGHTNESS 3 CONTINUOUS INTERSTITIAL 4 ELECTRONIC LINE 5 AUTOMATIC PUMP D. LEAK DETECTION DETECTOR TESTING [DMONITORING ❑ LEAK DETECTOR ❑ SHUTDOWN [:] 99 OTHER V.TANK LEAK DETECTION VISUAL CHECK ❑ 2 RECONCILMANUAL IATION ❑ 3 VADOZE MONITORING 4 AUTOMATGAUGING IC TANK ❑ 5 MON TORINGTER ❑ 6 ANNUAL TESTING R47 CONTINMOUOUS NITORING INTERSTITIAL ❑ 8 SIR ❑ g TAENK GAUGING TES❑10 MESTINGY TANK ❑ g5 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) 1.ESTIMATED DATE LAST USED(MO/O2.ESTIM6XEQ QUANTITY OF 3.WAS TANK FILLED WITH rT SUB AN S REMAINING GALLONINERT MATERIAL? THIS FORM HAS BEEN COMPLETED UNDE PEN LTY O ERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT TANK OWNER'S NAME D (PRINTED 6 SIGNATURE) A/)r LOCAL AGENCY USE ONLY c THE STATE I.D.N R IS COMPOSED OF THE FOUR NUMBERS BELOW �J COUNTY# JURISDICTION# FACILITY#IQRA71 TANK# STATE I.D.# m PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE ()i THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPON-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. F C MUST BE COMPLETED FOR INSTALLATIONS.THIS FORM SHOULD BE ACCOMPANIED BY A PLOT FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING IWEOUND ST/ORAGE TANK REGULATIONS FORM B (6-95) � Ir 1�