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STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD ;:"' M1'? UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B �� ° i COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY Q 1 NEW PERMIT Q 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLO SITE ONE ITEM ❑ 2 INTERIM PERMIT Q 4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE B TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: Jar o Y' I. TANK DESCRIPTION COMPLETE ALL ITEMS— SPECIFY IF UNKNOWN A OWNERS TANK I.D.# u B. MANUFACTURED BY: /Ju C. DATE INSTALLED(MOIDAY/YEAR) tiA D. TANK CAPACITY IN GALLONS: II.TANK CONTENTS IF A-1 IS MARKED,COMPLETE ITEM C. A, g I MOTOR VEHICLE FUEL Q 4 OIL B. C, 1a PEGULAR UNLEADED 3 DIESEL Q 6 AVIATIONGAS Q 2 PETROLEUM Q 80 EMPTY Q I PRODUCT ❑ tb PREMIUM UNLEADED Q 4 GASAHOL Q 7 METHANOL Q E::]3 CHEMICALPRODUCT ❑ 95 UNKNOWN EJ WASTE 2 2 LEADED 8 M85 EADEDE UNLEADED Q 5 JET FUEL Q Q LD Q 99 OTHER(DESCRIBE N REM D.BELOV✓) D. IF(A7)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 Q 3 SINGLE WALL WITH EXTERIOR LINER ❑ 5 INTERNAL BLADDER SYSTEM ❑ 95 UNKNOWN SYSTEM 2 SINGLE WALL ❑ 4 SINGLE WALL IN A VAULT Q 99 OTHER B. TANK 1 BARE STEEL Q 2 STAINLESS STEEL ❑ 3 FIBERGLASS Q 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL 5 CONCRETE Q 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ B 100% METHANOL COMPATIBLE WIFRP (Primary Tank) Q 9 BRONZE Q 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER C.INTERIOR Q I RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING Q 4 PHENOLIC LINING LINING OR ❑ 5 GLASS LINING 19 6 UNLINED ❑ 95 UNKNOWN Q 99 OTHER COATING IS LINING MATERIAL COMPATIBLEWITH100% METHANOL? YES_ NO— D.EXTERIOR ❑ 1 POLYETHYLENE WRAP 2 COATING Q 3 VINYL WRAP E:] 4 FIBERGLASS REINFORCED PLASTIC CORROSION PROTECTION ❑ 5 CATHODIC PROTECTION 1XI 91 NONE Q95 UNKNOWN ❑ 99 OTHER E.SPILL AND OVERFILL,MC. 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 A. SYSTEM TYPE I SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION A E I SINGLE WALL A U 2 DOUBLE WALL A U 3 UNED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND AU 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 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 0 UNKNOWN A U 99 OTHER D. LEAK DETECTION Q1 M9XMMGL NNE IF.U( 2 NNE IKWWSS 3 COMINaW3 WT%LI11AL 4 ELEC1Pa DNE 5 AVOW=PUN@ DIMI=1 E] nma MoM ma OF K o GTM ❑ snrtoowN ❑ 99 OTHER V.TANK LEAK DETECTION Q 1 VISUAL CHECK ❑ 2 MANAL INVENTRECOU CILIATONORV ANNUAL Q 3 MONITORING ❑ 4 GALA NG MATIC TANK Q S MON TORINGOUND WATER F-16 TESTNGTANK ❑ 7 CONTINUOUS MONITORINGTINUINTERSTITIALQ B SIR ❑ 9 TANK GAUGING Q 70 TESTING Y TANK ❑ 95 UNKNOWN Q 99 OTHER VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) 1.ES V D DATE LAST USED(MO/DAY/YR) 2.ESTIMATED QUANTITYOF uN4 GALLONS 3 WAINERT MATERIAL 7H YES [:] NO� M1M1-- SUBSTANCE REMAININING / — FI LL E D VVI THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT TANK OWNERS NAME DATE (PRWDNT LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY# TANK# STATE 01 ® SR;l� o PERMIT NUMBER PERMIT APPROVED BYIDATE PERMIT EXPIRATION DATE I D R7 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 SHOULD BE ACCOMPANIED BY A PLOT PLAT ETHIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UP" GROUND STORAGE TANK REGULATIONS FORMS (695) �� FORM34