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• STATE OFCAUFORNIA • �'`o STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION-FORM B `� is COMPLETE A SEPARATE FORM FOR TANK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSE NSITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ d AMENDED PERMIT 6 TEMPORARY TANK CLOSURE a 8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: G I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN /tl A OWNER'S TANK I.D.N B. MANUFACTURED BY: C. DATE INSTALLED(MC/DAY/YEAR) D. TANK CAPACITY IN GALLONS: II.TANK C NTENTS IF A-1 IS MARKED,COMPLETE ITEM C. 1 MOTOR VEHICLE FUEL 4 OIL g. C 1a REGUI R UNLEADED 3 DIESEL ❑ 6 AVIATION GAS A ❑ 2 PETROLEUM ❑ 80 EMPTY 1 PRODUCT ❑ 10 PREMIUM UNLEADED 4 GASAHOL ❑ 7 METHANOL ❑ is MIDGRADE UNEADED 5 JET FUEL ❑ 8 M65 O 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED 99 OTHER(DESCRIBE IN REM D.BELOM 0. IF(Ai)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S.tl: 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 ❑ OUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR UNER ❑ 5 INTERNAL BLADDER SYSTEM ❑ 95 UNKNOWN SYSTEM 2 SINGLE WALL ❑ d 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 UMINUM ❑ B 100% METHANOL COMPATIBLE W/FRP (Primary Tank) ❑ g BRONZE O 10 GALVANIZED STEEL 95 UNKNOWN ❑ 99 OTHER C.INTERIOR ❑ i RUBBER LINED ❑ 2 ALKYD LINING ❑ OXY LINING ❑ 4 PHENOLIC UNING LINING OR ❑ 5 GLASS UNING ❑ 6 UNLINED kj 95 UNKNOWN ❑ 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES— NO— D.EXTERIOR ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC CORROSION PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE 95 UNKNOWN ❑ 99 OTHER E SPILL AND OVERFILL,BSO. SPILL CONTAINMEW INSTALLED(YEAR( OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) DROP TUBE YES_ NO_ STRIKER PLATE YES NO_ DISPENSER CONTAINMENT YES_ NO W.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 AG 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 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 8 100% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEELU 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION 1 NEau+arx ld1E t£Nc 2 uxE nGHrxess 3 c6Nlwuas Ix�mimu 4 Br:cl K UNE 5 AVOWTIC ww ❑ OEIECfOR TESTING ❑ w m m LEAK DETE=R 9Rnp m ❑ 99 OTHER V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK 2 MANUAL INVENTORY ❑ 3 VADOZEON MONITORING ❑ 4 GAUGING C TANK ❑ 5 MONITORINGDWATER 6 ANSnAL TANK ❑ 7 CONTINUOUS MONITORING INTERSTITIAL ❑ 0 SIR ❑ 9 TANK�GAUG NGAL ❑10 TESTING Y TANK ❑ 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PUCE) 1.ESTIMATED DATE LAST USED(MO/DAYNR) 2.ESTIMATED QUANTITY OFI 3.WAS TANK FILLED WITH YES ❑ NO F-1SUBSTANCE REMAINING GALLONS INERT MATERIAL 7 THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT TANK OWNER'S NAME DATE (PRINTED&SIGNATURE) LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY a JURISDICTION a FACIUTY# TANK k STATE I.D.# F37T 02 (a 1 ,5d.311 U 5 1515110 PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION UATE C J THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORMA,UNLESS A CURRENT FORMA HAS BEEN FILED. FORM C MUST BE COMPLETED FOR INSTALLATIONS. IS FORM SHOULD BE ACCOMPANIED BY A PLOT A_&E THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING TH(GROUND STORAGE TANK REGULATIONS R_ !T1 CC (6 FORM B .95) F�Na03R&'I