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'tyOURGf9 C STATE OF CALIFORNIA Ar ° STATE WATER RESOURCES CONTROL BOARD W� , UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B a �l.er o •OSI If OR N,� COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CtOqED-_QtLSITE fONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE y f` 8 TANK REMOVE DBA OR FACILITY NAME WHERE TANK IS INSTALLED: A K I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN IL A. OWNER'S TANK I.D.# AMMW B. MANUFACTURED BY: C. DATE INSTALLED(MO/DAYNEAR) /Yoe 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 ❑ 2 PETROLEUM ❑ 80 EMPTY " 1 PRODUCT ❑ lb PREMIUM UNLEADED ❑ 4 GASAHOL ❑ 7 METHANOL ❑ 1c MIDGRADE UNLEADED ❑ 5 JETFUEL ❑ 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.#: E. 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 ❑ 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 ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING LINING OR ❑ 1k 5 GLASS LINING ~6 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO— D.EXTERIOR ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC CORROSION PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE r"`g 5 UNKNOWN ❑ 99 OTHER SPILL CONTAINMENT INSTALLED(YEAR) —O'VVEERFILL PREVENTIOt1 EQUIPMENT INSTALLED(YEAR) E.SPILL AND OVERFILL,EIC. DROP TUBE YES NO 'WlKtFTPLATE YES NO DISPENSER CONTAINMEN-fY S NO :7 , IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION AUr= 2 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION A 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(p 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 A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION1 MECHANICAL UNE LEAK �❑ DETECTOR ❑2 LINE TIGHTNESS 3 CONTINUOUS INTERSTITIAL 4 ELECTRONIC UNE 5 AUTOMATIC PUMP TESTING ❑ MONITORING ❑ LEAK DETECTOR ❑ SHUTDOWN ❑ 99 OTHER V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK j 2 RECONCILMANUAL IIATIONORY ❑ 3 MONIITORING ❑ 4 GAUGING VAOZEAUTOMATIC TANK E::]5 MONITORING GROUND TER ❑6 TESTINGTANK ❑ 7 CONTINUMON TOR U INTERSTITIAL ❑ 8 SIR ❑ 9 WEEK LY MANUAL ❑10 MOTESTINGHL TANK ❑ 95 UNKNOWN ❑99 OTHER VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) 1.ESTIMATED DATE LAST USED(MO/DAYNR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES [:] NO ❑ o'? SUBSTANCE REMAINING GALLONS INERT MATERIAL? THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJU Y,AND XO TIJE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT TANK OWNER'S NAME DATE (PRINTED 8 SIGNATURE) �Jl 1` L41 v I o LOCAL AGENCY USE ONLY VTHE STATE I.D.NUMBER IS COMPOSED OF THE FO NUMBERS BELOW COUNTY# JURISDICTION# FACILITY# TANK# STATE LD:# tAfA-- F17T] 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 (6-95)