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BTATEOF CALIFORNIA • c 9 w� Wa o STATE WATER RESOURCESCONTPOLBOAPD UNDERGROUND STORAGE TANK PERMIT APPLICATION-FORM B t COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. ❑ 7 PERMANENTLY CLOSED ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 8 TANK REMOVED MARK ONLY ❑ I NEW PERMIT ❑ ❑ 6 TEMPORARY TANK CLOSURE ONE R'EM ❑ 2 INTERIM PERMIT 4 AMENDED PERMIT DBA OR FACILITY NAME WHERE TANK IS INSTALLED: I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN B. MANUFACTURED BV: A OWNER'S TANK 1.D.N C. DATE INSTALLED(MO'DAV/YEAR) D. TANK CAWE] PACITY IN GALLONS: IL TANK CONTENTS IF A-1 IS MARKED,COMPLETE ITEM C. 1a REGULAR UNLEADED 3 DIESEL ❑ 8;AVIATION GASp. IMOTOR VEHICLE FUEL ❑ 4 OIL B. �Ic�--�/ C' ❑ ib PREMIUM UNLEADED g 4 GASAHOL ❑ 7HANOL2PETROLEUM ❑ 80 EMPIV !'�-'�1 PRODUCT ❑ Ic MDGPADE UNLEADED ❑ 5 JETFUEL ❑ 83 CHEMICALPRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED ❑ 99 OTHER(DESCRMEIN .BELOW) D. IF(A1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED 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 UNER ❑ 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 ❑ s CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 6 100% METHANOL COMPATIBLE W/FRP (PrimaryTmIQ ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER C.INTERIOR ❑ I RUBBER LINED ❑ 2 ALKYD UNING ❑ 3 EPDXY UNING ❑ 4 PHENOUC UNING LINING OR ❑ 5 GLASS UNING ❑ 6 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER COATING IS LINING MATERIAL COMPA71BLE WITH 10D% METHANOL? VES_ NO— D.EXTERIOR ❑ I POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC CORROSION PROTECTION ❑ 5 CATHODIC PROTECnON ❑ 91 NONE F-1 95 UNKNOWN ❑ 99 OTHER E SPILL AND OVERFILL,61C. SPILL CONTAINMENT INSTALLE (YEAR) OVERFILL PREVEN O EQUIPMENT INSTALLED(YEAR) DROP TUBE YES_ NO TRIKER PLATE YES_ NO DISPENSER CONTAINMENT YES_ NO IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND,BOTH IF APPUCABLE 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 U I 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 STEELW/COATING A U 8 100% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION q U 95 UNKNOWN p U 99 OTHER D. LEAK DETECTION ❑1 �cl ,m UNE IFAx ❑2 4,9'r pMlBEa ❑3 coxrlxuas IxrDrsTmu ❑4 D.EmIKMc uM: ❑s AurwATK ww CETECiOR p L 111 s M OEIECTU aNDICDNN OTHER V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK 2 RECONCILIATION ❑ 3 MAODNOITORING ❑ 4 AUTOGAUMATIC TANK ❑5 MONITORING D WATER 8 ANNUAL TANK ❑ 7 MONITORING INTERSTITIAL ❑ 8 SIR ❑ 9 WEEKLY MANUAL ❑ 10 MONTHLY TANK 95 UNKNOWN TANK GAUGING TESTING ❑ ❑99 OTHER VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) I.ESTIMATED DATE LAST USED(MO/DAYNS) 2.ESTIMATED OUANTITY OF 3.WAS TANK FILLED WITH SUBSTAGE REMAINING GALLONS INERT MATERIAL YES ❑ NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT TANK OWNER'S NAME OATS (PRINTED 4 BIDNATURQ LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW STATE I,D.# COUNTY N JURISDICTION M FACILITY N TANK X �T PERMIT NUMBER PERMIT APPROVED BYIDATE I-L�L_L_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 FORM B (6-95) SHOULD BE ACCOMPANIED BY A PLOT PLAM. FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UMnERGROUND STORAGE TANK REGULATIONS Q / — zea b