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• STATE OFCAUFORNIA • STATE WATER RESOURCES CONTROL BOARD ,o UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B ""� �A, COMPLETE A SEPARATE FORM FOR? H TANK SYSTEM. MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOS ONSITE ONE REM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ B TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: 1. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN / A OWNER'S TANK I.D.Y O21 1 8. MANUFACTURED BY: , C. DATE INSTALLED(MCIDAYNEAR) D. TANK CAPACITY IN GALLONS:�v II.TANK CONTENTS IF A-1 IS MARKED.COMPLETE ITEM C. A 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C. 1a AEGULAR UNLEADED 3 DIESEL ❑ 6 AVIATION GAS ❑ 2 PETROLEUM ❑ BO EMPTY 1 PRODUCT 1D PREMIUM UNLEADED ❑ 4 GASAHOL ❑ 7 METHANOL ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE Q 8 M85 2 LEADED EDE UNFAOED 0 99 (DESCRIBE N ITEM o.BB.om D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.X S.# III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES 0.S.AND C.AND ALLTHAT APPLIES IN BOX D AND E A. TYPE OF ❑ 1 BLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 5 INTERNAL BLADDER SYSTEM ❑ 95 UNKNOWN SYSTEM Ejr2 SINGLE WALL ❑ 4 SINGLE WALL IN A VAULT ❑ 99 OTHER B. TANK ❑ 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD Wl FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ fi POLYVINYL CHLORIDE n 7 AWMINUM ❑ 8 100% METHANOL COMPATIBLE WIFRP (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL T 9955 UNKNOWN ❑ 99 OTHER C.INTERIOR ❑ I RUBBER UNED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC UNING LINING OR ❑ 5 GLASS UNING ❑ 6 UNUNED rE-�5UNKNOWN ❑ 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_}}}}yyffNR!l11ttttNNVNNVO— D.EXTERIOR ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 L WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC CORROSION —�y/ PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE 95 UNKNOWN ❑ 99 OTHER E SPILL AND OVERFILL,BTC. 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 A 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION A(U�>l SINGLE WALL A U T DOUBLE WALL A U 3 UNED 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 5T(��E)L W/COATING A U 5 100% METHANOL COMPATIBLE WIFRP PROTECTION A U 9 GALVANIZED STEEL 10 CATHODIC PROTECTION AV 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION 1 uEn m UNE Is_4x 2 UNE nGx w 3 WNnNV0u51NTasnn¢ 4 ELEcrnawc UNE 5 AVOW=WNR ❑ E Cron MnNG MONRd a LEAK O CMR SHUf1bWN ❑ 99 OTHER V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK 2 RINVENTORY ❑ 3 ❑ 4 C TANK TER 6 TEST'NTANK RECONCILIATION MONITORING GAUGING MONITORING IG 7 MONITORU INTERSTITIAL ❑ 8 SIR ❑ 9 WE KLY GAUG NGAL ❑ 10 MOTESNTHLY TANK 95 UNKNOWN ❑ 99 OTHER NG VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) 1.ESTIMATED DATE LAST USED(MO/DAYNR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES ❑ NO❑ SUBSTANCE REMAINING 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 DATE (PRNTED 6 SIGNAMRE) LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY# TANK# STATE I.DJ M41 Pq�zkl 2 I isdZql iz-VI2 in PERMIT NUMBER PERMIT APPROVED BYIDATE PERMIT EXPIRATION DATE THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORMA HAS BEEN FILED. FORMS MUST BE COMPLETED FOR INSf TIONS. THIS FORM SHOULD BE ACCOMPANIED BY A PLOT THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING TH ROUND STORAGE TANK REGULATIONS q.(foA4� FORMS (6-95) P'` L FORW34 B�/I"