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STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION -FORM B , COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ON SITE ONE TEM 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ B TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: I. TANK DESCRIPTION COMPLETE ALL ITEMS— SPECIFY IF UNKNOWN /L A OWNERS TANK I.D.# —2 B. MANUFACTURED BY: C. DATE INSTALLED(MOIDAY/YEAR) D. TANK CAPACITY IN GALLONS: IL TANK CONTENTS IF A-1 IS MARKED,COMPLETE ITEM C. I MOTOR VEHICLE FUEL O I OIL B. C. 1a REGULAR UNLEADED ❑ 3 DIESEL ❑ 8 AVIATION GAS A 2 PETROLEUM W EMPTY ❑ 1 PRODUCT lc PREMNM UNLEADED ❑ 4 JET FUEL ❑ 7 METHANOL ❑ ❑ 1c MIOGRADE UI-LEADED � 5 JET FUEL ❑ 8 M85 ❑ 3 CHEMICALPRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED 99 01HER(DESCRIBE N ITEM D.BELOW) D. IF(AA)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 LINER ❑ 5 INTERNAL BLADDER SYSTEM ❑ 95 UNKNOWN SYSTEM r2<2 SINGLE WALL ❑ 4 SINGLE WALL IN A VAULT ❑ 99 OTHER B. TANK1 BARE STEEL ❑ 2 STAINLESS STEEL F73 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL E❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE WIFRP (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER C.INTERIOR ❑ 1 RUBBER UNED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING LINING OR ❑ 5 GLASS LINING ❑ 6 UNLINED ��95 UNKNOWN ❑ 98 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NOS\ D.EXTERIOR ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC CORROSION PROTECTION [:] 5 CATHODIC PROTECTION >91.,9I NONE ❑95 UNKNOWN ❑ 89 OTHER E.SPILL AND OVERFILL,aTC. SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTIO E UIPMENT INSTALLED(NEAR) IVV DROP TUBE YES NO IKER PLATE YES_ NO DISPENSER CONTAINMENT YES_ NO IV.PIPING INFORMATION CIRCLE A IFASOVEGROUNDOR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE AU SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION A 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)A U 4 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL W/COATING A U B 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 l aECHNAaa-MIE" 2 IrE 00Hr M 3 canraE)ws rrrFAsmut 4 E120 =DRE s AumaAnc FUIF ❑ DEI MR ❑ TEs9H3 ❑ aaatoRma IENt oETEcrOR ❑ sHur00xTI 9 OTHER V.TANK LEAK DETECTION �( GROUND ..�� (( ❑ 1 VISUAL CHECK ISL 2 RECOU CIUATIONAL ORV ❑ 3 MONIITORING OZE ❑ 4 GAUGING AUTOMATIC TANK ❑ 5 MONITORING TESTING TESTINGANNUALTANK ❑ 7 CONTINUOUS ON INU U INTERSTITIAL 8 SIR ❑ 9 WEETANK GAUGING ❑10 TESTING40HLY TANK ❑ 95 UNKNOWN 99 OTHER VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) 1.ESTIMATED DA T SED(MO/DAYNR) 2 ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH SUBSTANCE REMAINING GALLONS IN MATERIAL? YES ❑ NO❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT TANK OWNERS NAME DATE (PRMTED 6 SIGNATURE) LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY# TANK# STATE I.D.# PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORMA HAS BEEN FILED. FORM C MUST BE COMPLETED FOR INST LLAT N .THIS FORM SHOULD BE ACCOMPANIED BY A PLOT PL•" FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE v--nERGROUND STORAGE TANK REGULATIONS FORM B (695) ` `� FORW349-RT