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STATE OF CALIFORNIA :P ...... STATE WATER RESOURCES CONTROL BOARD 3 L UNDERGROUND STORAGE TANK PERMIT APPLICATION -FORM B 1 j •CSL 1/011 H1� COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. 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: CR,UI�r_ STOP (Z I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN vC A. OWNER'S TANK I.D.# 1�t_2 B. MANUFACTURED BY: C. DATE INSTALLED(MO/DAYNEAR) I-1 SJ D. TANK CAPACITY IN GALLONS: If.TANK NTENTS IF A-1 IS MARKED,COMPLETE ITEM C. q i MOTOR VEHICLE FUEL ❑ 4 OIL B. C ❑ to REGULAR UNLEADED ❑ 3 DIESEL ❑ 6 AVIATION GAS ❑ PREMIUM UNLEADED ❑ 4 GASAHOL ❑ 7 METHANOL F-] 2 PETROLEUM ❑ 80 EMPTY 1 PRODUCT is ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN MIDGRADE UNLEADED ❑ 5 JET FUEL ❑ 8 MBS El2 WASTE E] 2 LEADED ❑ 99 OTHER(DESCRIBE IN ITEM D.BELOM D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S.#: III. TANK CONSTR TION 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 ❑ 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 COMPATIBLE W/FRP (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER C.INTERIOR ❑ 1 RUBBER LINED ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING LINING OR ❑ 5 GLASS LINING �r6 UNLINED ❑ 95 NKNOWN ❑ 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO_ D.EXTERIOR ❑ CORROSION 1 POLYETHYLENE WRAP ❑ 2 COATING F-] 3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC PROTECTION E::] 5 CATHODIC PROTECTION 91 NONE 1:195 UNKNO N E] 99 OTHER E.SPILL AND OVERFILL etc. SPILL CONTAINMENT STALLED(YEAR) OVERFI EVENTION 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 2 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION A U 1 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)AU 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 CATHOD PROTECTION A U 95 UNKNOWN U 99 OTHER D. LEAK DETECTION ❑1 MECHANICAL UNE LEAK 2 LINE TIG147NESS 3 CONTINUOUS INTERSTINTERSTITIAL4 ELECTRONIC LINE 5 AUTOMATIC PUMP DETECTOR ❑ TESTING MONITORING ❑ LEAK DETECTOR SHUTDOWN ❑ 99 OTHER V.TANK LEAK DETECTION ❑ VISUAL CHECK 1:12 ECONCIL ATIONMANUAL INVENTORY E:] 3 MONITORING VADOZEIn 4 GAUGING AUTOMATIC TANK ❑ 5 MONITORINGGROUND WATER ❑ 6 ANNUAL TESTINGTANK 7 ff MONITORCONTINUOUS ❑ 8 SIR ❑ 9 WEEK LY MANUAL F-110 MO T HLY TANK E::] 95 UNKNOWN E:] 99 OTHER VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) 1.ESTIMATED DATE LAST USED(MO/DAY/YR) �/ 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES SU NCE REMAINING GALLONS INERT MATERIAL? THIS FORM HAS BEEN COMPLETED UNDER PE ALTY F RJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT TANK OWNER'S NAME ` DATE (PRINTED&SIGNATURE) I IKe z'� ( �8 LOCAL AGENCY USE ONLY THE STATE I. C OSED OF THE FOUR NUMBERS BELOW `� COUNTY# JURISDICTION# FACILITY# TANK# STATE I.D.# m 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 PJWILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING TH RGROUND STORAGE TANK REGULATIONS FORM B (6-95)