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't50Vw Rl5 C STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B • C�IIRONNR ` COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM, MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT gL', 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLLOSE SI ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: RQ�� ❑ 2 STAINLESS STEEL 3 FIBERGLASS L TANK DESCRIPTION COMPLETE ALL ITEMS - SPECIFY IF UNKNOWN A OWNER'S TANK I. D. # � B. MANUFACTURED BY: fe r+ � C. DATE INSTALLED (MO/DAWYEAR) � D. TANK CAPACITY IN GALLONS: OW 11_ TANK CONTENTS IF A-1 IS MARKED. COMPLETE ITEM C. p,_ ❑, 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. �1 PRODUCT C ❑ to REGULAR UNLEADED ❑ 3 DIESEL ❑ 6 AVIATION GAS 21] 1b PREMIUM UNLEADED ❑ 4 GASAHOL ❑ 7 METHANOL 2 PETROLEUM 80 EMPTY ❑ ❑ A. TYPE OF SYSTEM ❑ lc 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. #: 111_ TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A. B. AND C, AND ALL THAT APPLIES IN BOX D AND E IV PIPING INFORMATION rlArl F A IF ABOVE GROUND OR U IF UNDERGROUND. BOTH IF APPLICABLE A. SYSTEM TYPE ❑ 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 5 INTERNAL BLADDER SYSTEM ❑ 95 UNKNOWN A. TYPE OF 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 ❑ 5 GLASS LINING . 6 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 100°/6 METHANOL? YES_ NO— D. EXTERIOR ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC CORROSION ❑ 5 CATHODIC PROTECTION 1:191 NONE ❑ 95 UNKNOWN ❑ 99 OTHER PROTECTION 44146 SPILL CONTAINMENT, INSTALLED (YEAR) OVERFI LPREVENTION EQUIPMENT INSTALLED (YEAR) E. SPILL AND OVERFILL, BtC. DROP TUBE YES NO STRIKER PLATE YES'' NO DISPENSER CONTAINMENT YES NO IV PIPING INFORMATION rlArl F A IF ABOVE GROUND OR U IF UNDERGROUND. BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION AL L PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL A DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND CORROSION PROTECTION A U A U A U 1 BARE STEEL 5 ALUMINUM 9 GALVANIZED STEEL A U A U A U 2 STAINLESS STEEL A U 6 CONCRETE A U 10 CATHODIC PROTECTION 3 POLYVINYL CHLORIDE (PVC)A << d4 FIBERGLASS PIPE E. 7 STEELW/COATING A U 8 100% METHANOL COMPATIBLEW/FRP A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION [—] 1 MECHANICAL UNE LEAK ❑ DETECTOR 2 LINE TIGHTNESS 3 CONTINUOUS INTERSTMAL 4 ELECTRONIC LINE TESTING MONITORING LEAK DETECTOR 5 AUTOMATIC PUMP [:]99 OTHER SHUTDOWN V. TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 MANUAL INVENTRECONCIL ATIONORY ❑ 3 MONIITORING [aVAOZE4 GAUGING AUTOMATIC TANK ❑ 5 MON TORINGGROUND WATER ❑ 6 TESTINGTANK 7 MONITORING INTERSTITIAL ❑ 8 SIR ❑ 9 WEEKLY MANUAL ❑ 10 M STINGY 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 ❑ SUBSTANCE REMAINING GALLONS INERT MATERIAL? THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PER URY, ANq TO THE BEST OF MY KNOWLEDGE, IS TR E AND CORRECT DATE_ / TANK OWNER'S NAME (PRINTED 6 SIGNATURE)1"v=42& LOCAL AGENCY USE ONLY THE STATE I.D. NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY # JURISDICTION # FACILITY # TANK # STATE I.D.# ❑❑ ❑❑] I]= d V4 PERMIT NUMBER PERMIT APPROVED BY/DATE I PERMIT EXPIRATION DATE THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLI� - FORM A, UNLESS A CURRENT FORM A HAS BEEN FILED. FOM BE COMPLETED FOR INSTALLATIONS. THIS FORM SHOULD BE ACCOMPANIED BY A PLOT P LE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE GROUND STORAGE TANK REGULATIONS FORM B (s5)