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• STATE OFCAUFORNIA 0 STATE WATER RESOURCES CONTROL BOARD g UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B ' �n COMPLETE A SEPARATE FORM FORE ANK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE ONE REM F72 INTERIM PERMIT ❑ < AMENDED PERMIT fi TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED {=A DBA OR FACILITY NAME WHERE TANK IS INSTALLED: 5`l-' C F I'a I. TANK DESCRIPTION COMPLETE ALL ITEMS— SPECIFY IF UNKNOWN [ti X OWNER'S TANK I.D.Y B. MANUFACTURED BY: C. DATE INSTALLED(MO/DAWYEAR) D. TANK CAPACITY IN GALLONS: II.TANK 900ENTS IF A-1 IS MARKED.COMPLETE ITEM C. A 1 MOTOR VEHICLE FUEL ❑ 4 OIL 8. C. to REG UNLEADED ❑ 3 DIESEL ❑ 8 AVIATION GAS ❑ 2 PETROLEUM ❑ 80 EMPTY 1 PRODUCT ❑ 1 MIUN UNLEADED ❑ 4 GASAHOL ❑ 7 METHANOL is MIDGRADE UNLEADED ❑ 5 JETFUEL ❑ 8 M85 ❑ 3 CHEMICALPRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED ❑ 99 OTHER(DESCRIBE IN REM D.BELOW) D. IF(A.1)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 LISLE 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 FIB SS ❑ 6 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 UMINUM ❑ B 100% METHANOL COMPATBLE WIFRP (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL 95 UNKNOWN ❑ 99 OTHER C.INTERIOR ❑ I RUBBER UNED ❑ 2 ALKYD UNING ❑ 3 WOXY LINING ❑ 4 PHENOLIC LINING LINING OR ❑ 5 GLASS UNING ❑ 6 UNLINED 95 UNKNOWN ❑ 99 OTHER COATING IS LINING MATERIAL COMPATBLE WITH 100% METHANOL? YES— NO_ D.EXTERIOR ❑ i POLYETHYLENE WRAP ❑ 2 COATING [:] 3 WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC CORROSION PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE 95 UNKNOWN ❑ 99 OTHER E.SPILL AND OVERFILL,etc. 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 IFUNDERGROUNO,BOTH IFAPPUCABLE A. SYSTEM TYPE 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION A&1 SINGLE WALL A U Z 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 CONCRETE A U 7 STEEL W/COATING A U 8 100% METHANOL COMPAT18LE WIFRP PROTECTION A U 9 GALVANIZED STEEL 10 CATHODIC PROTECTION A(U95 UNKNOWN A U 99 OTHER 99 O U 2 UNE D D. LEAK DETECTION ❑1 MECNN m IRIS IF/% ain ESS 3 CCmINUWS IME8911IIAL 4 EIECTRWIO NE 5 AUTOMATIC MWTHER ��R TEyTwa ❑ WWMING LEAH oETEcrcA 9Artoavm ❑ V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK 2 RECONCILIATIONMANUAL ORV ❑ 3 VADOZEMONITORING ❑ 4 AUTOMATIGAUGING MONITORING TANK ❑ 5 MONTORINGOUND WATER e TESTINGTANK ❑ 7 CONMON INUOU INTERSTITIAL ❑ 8 SIR ❑ 9 TANK LY MANUAL ❑10 M SNTHLY TANK ❑ 95 UNKNOWN ❑99 OTHER ORING TTTNG VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) 1.ESTIMATED DATE LAST USED(MOIOAYNR) 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 (PRINTED 8 SIGNATURE) LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION M FACILITY# TANK M STATE I.D.# F—�7q F3-a&I3 -xal a fL I A PERMIT NUMBER PERMIT APPROVED BYIDATE PERMIT EXPIRATION DATE / THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPUC FORM A,UNLESS A CURRENT FORM A HAS BEEN FlLED . FO UST BE COMPLETED FOR INSTALLATIONS.THIS FORM SHOULD BE ACCOMPANIED BY A PLOT THIS FORM WITH THE LOCAL AGENCY IMPLEMFMING THFfl0UN0 STORAGE TANK REGULATIONS FORMS (6-95) L-.-� FORW34