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STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION-FORM B H COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLO E ONE ITEM F-12 INTERIM PERMIT ❑ 4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE 8 TANK REMOVED ' DBA OR FACILITY NAME WHERE TANK IS INSTALLED: I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A OWNER'S TANK I.D.# aAa- B. MANUFACTURED BY: We— C. DATE INSTALLED(MODAY/YEAR) UN-, D. TANK CAPACITY IN GALLONS: I II.TANK CONTENTS IF A-1 IS MARKED.COMPLETE ITEM C. A 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C. le REGUUR UNLEADED Q 3 DIESEL ❑ 6 AVIATION GAS ❑ :PREMIUM UNLEADED ❑ 4 GASAHOL ❑ 7 METHANOL ❑ 2 PETROLEUM ❑ BO EMPTY w 1 PRODUCT ❑ 1C MDGRAOE UFLLEADEDn��'I 5 JET FUEL ❑ 6 M85 ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE El LEADED u 99 OTHER(DESCRIBE W ITEM D.BELOW) D. IF(At)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S.N: 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 (P11m1YTanW ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER C.INTERIOR ❑ 1 RUBBER UNED ❑ 2 ALKYD UNING ❑ 3 EPDXY LINING ❑ 4 PHENOUC LINING LINING OR ❑ 5 GLASS LINING u 6 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER COATING IS LINING MATERIAL COMPATIBLlWITH 10D% METHANOL? YES_ NO— D.EXTERIOR ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC CORROSION PROTECTION ❑ 5 CATHODIC PROTECTION B1 NONE E] 95 UNKNOWN ❑ 99 OTHER E.SPILL AND OVERFILL,BTC. SPILL CONTAINMENT NSTALLED(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 A. SYSTEM TYPE A 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION A W-1 SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND Al U 1 BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A U 4 FIBERGLASS PIPE CORROSION A 5 ALUMINUM A U B CONCRETE A U 7 STEEL W/COATING A U B 100% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODICPROTECTION A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION 1 KEaHNMGu UNE LEAK 2 ME T414NESs 3 CONNNUWS IN1E0.5111VL 4 ELEG1RdVIC UNE s AUf01MiIC MNP ❑ OERCTOR ❑ TESTMU ❑ MONTORMG ❑ UAK OEiECTW ❑ 9XI1I10NRH ❑ 99 OTHER V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 q CO CIU TIONUAL ORY ❑ 3 MONITORING ❑ 4 GAUL NG AUTOMATIC TANK ❑ 5 MONITORINGTER ❑6 TEGROUND ❑ 7 NRUINTERSTITIAL ❑ 8SIR ❑10 MONTHLY TANK ❑ 95 UNKNOWN 99 OTHERpEGMOTOTANK GAUGING TESTING VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE N-PLACE) 1.ESTlW,P LATE LAST USED(MO/DAYNR) 2.ESTIMATED QUANTITY OF //ll L 3.WAS TANK FILLED WITH YES ❑ NO `t��_ SUBSTANCE REMAINING l� f- GALLONS INERT MATERIAL THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT TANK OWNER'S NAME //11 }� DATE/ Q (PRINTED551GNATURE) 4A/(IJ LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY# ' n TANK# STATE I.D.# PERMIT NUMBER PERMIT APPROVED BYIDATE PERMIT EXPIRATION DATE THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATNIN-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 PLAT IE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UV ,)GROUND STORAGE TANK REGULATIONS FORM B (6-95) .� FOR0034