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b `eou�cea STATE OF CALIFORNIA .° ' cOti. 0 STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM B p; •C�111011M� COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION 10,7 PERMANENTLY CLOSED ON SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TAN CLOSURE 8 TANK REMOVED M 'PE DBA OR FACILITY NAME WHERE TANK IS INSTALLED• I. TANK DESCRIPTION COMPLETE ALL ITEMS– SPECIFY IF UNKNOWN A. OWNER'S TANK I.D.# B. MANUFACTURED BY: / C. DATE INSTALLED(MO/DAY/YEAR) D. TANK CAPACITY IN GALLONS: �" S II.TANK CONTENTS IF A-1 IS MARKED,COMPLETE ITEM C. A. ❑ i MOTOR VEHICLE FUEL ❑ 4 OIL B. C. ❑ 1a REGULAR UNLEADED ❑ 3 DIESEL ❑ 6 AVIATION GAS ❑ 2 PETROLEUM ❑ 80 EMPTY ❑ 1 PRODUCT ❑ 1b 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.BELOIAQ D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED f 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 ❑ 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 5 INTERNAL BLADDER SYSTEM ❑ 95 UNKNOWN SYSTEM 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) E] 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER I ' C.INTERIOR ❑ 1 RUBBER LINED ❑ 2 D LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING LINING OR ❑ 5 GLASS LINING 8 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 i CORROSION PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE ❑°�35 F 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 i A. SYSTEM TYPE A U 1 SUCTION A U 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 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 DETECTION ❑1 MECHANICAL LINE LEAK ❑2 LINE TIGHTNESS ❑3 CONTINUOUS INTERSTITIAL ❑4 ELECTRONIC UNE ❑5 AUTOMATIC PUMP 99 OTHER DETECTOR TESTING MOMTORINO LEAK DETECTOR SHUTDOWN V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 MANUALRECONC?INVENTORY ❑ 3 IATION MONOITORING ❑ 4 GAUGING AUTOMATIC TANK ❑5 MONITORINGGROUND TER ❑6 TESTINGANNUAL E:] 7 CONTINUOUSMONITORING INTERSTITIAL ❑ 8 SIR ❑ 9 TpENK GAUGANGAL ❑10 TESTINGMONTHLTANK ❑.,gb UNKNOWN ❑99 OTHER VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) 1.ESTIMATED jSEjD(MO/DAY/YR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES ❑ NO fffl SUBSTANCE REMAINING GALLONS INERT MATERIAL? THIS FORM HAS BEEN PL ED WDER JeNAL. ERJURY,A TO T E BEST OF MY 9WL ,IS TRUE AND C RRECT TANK OWNER'S N ATE (PRINTED S SIGNA LOCAL AGENCY US ONLY THE STATE I.D.NUMBER IS COMP SED OF TH OUR NUkfBERS BELOW COUNTY# JURISDICTION# FACILITY# TANK# STATE I.D:# ❑❑ ❑❑ PERMIT NUMBER PERMIT APPROVED BYIDATE PERMIT EXPIRATION DATE I 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 I SHOULD BE ACCOMPANIED BY A PLOT PLA LE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UN RGR#OrUNjD{STORAGE TANK REGULATIONS FORM B (6-95) 1 �+�J