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• STATE OF CALIFORNIA • ��.w+ce STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B COMPLETE A SEPARATE FORM FOR TANK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSE N SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE ❑ B TANK REMOVED ce DBA OR FACILITY NAME WHERE TANK IS INSTALLED: (� I. TANK DESCRIPTION COMPLETE ALL ITEMS— SPECIFY IF UNKNOWN A OWNER'S TANK I.D.♦ Ink B. MANUFACTURED BY: C. DATE INSTALLED(MODAYNEAR) Q IIL- D. TANK CAPACITY IN GALLONS: II.TANK C NTENTS IF A-1 IS MARKED,COMPLETE ITEM C. A Eil" MOTOR VEHICLE FUEL ❑ 4 OIL B. C. 1S REGULAR UNLEADED ❑ 3 DIESEL ❑ 6 AVIATION GAS F-12 PETR1 PRODUCT OLEUM ❑ 80 EMPTY ❑ lb PREMIUM UNLEADED ❑ 4 GASAHOL ❑ 7 METHANOL ❑ 1c MIDGRADE UNLEADED ❑ 5 JETFUEL ❑ 8 M85 ❑ 3 CHEMICALPRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED ❑ 99 OTHER(DESCRIBE IN ITEM D.BELOW) D. IF(A1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S.0: 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 ❑ 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 ❑ 6 POLYVINYL CHLORIDE EUMINUM ❑ B 100% METHANOL COMPATIBLE W/FRP (PNmery Tank) ❑ g ggpN2E ❑ 10 GALVANIZED STEEL 95 UNKNOWN ❑ 99 OTHER C.INTERIOR ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ OXY LINING E:] 4 PHENOLIC UNING LINING OR F-15 GLASS UNING ❑ 6 UNLINED 95 UNKNOWN ❑ 99 OTHER COATING IS UNING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO— D.EXTERIOR ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING I� VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC CORROSION u�/ 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 AID 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLEPIPING A U 99 OTHER B. CONSTRUCTION A& 1 SINGLE WALL A U 2DOUBLE 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 WIFRP PROTECTION A U 9 GALVANIZED STEEL U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION 1 ETE WCHN4CAL UNE TEAK 2 UNE TI wK!M 3 f UWS IMERSmML 4 ELECTRONIC UNE 5 AWIN TIC PUMP ❑ Dw TESRNG MMTGRNG UW GETEGfOP ❑ 64DiWI5R1 ❑ 99 OTHER V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK 2 RECONCILIATIONMANUAL MONITORING ❑ 3 MONIITORING OZE ❑ 4 GAUGING AUTOMATIC TANK ❑ 5 GROUND MONITORINGTER 8 TESTING ❑ 7 MONITORING INTERSTITIAL ❑ 8 SIR ❑ S TANK LY MANUAL ❑10 MONTHLY TANK ❑ 95 UNKNOWN G TESTING ❑ 99 OTHER VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) 1.ESTIMATED DATE LAST USED(MOIDAYNR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES NO SUBSTANCE REMAINING GALLONS IN MATERIAL? ❑ o 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 8 JURISDICTION A FACILITY N TANK R STATE I.D.# F3-ffl © a 3 ! g 5 5 0 PERMIT NUMBER PERMIT APPROVED BYIDATE PERMIT EXPIRATION DATE C THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLI ION-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. FORM C MUST BE COMPLETED FOR INSTALLATIONS. T IS FORM SHOULD BE ACCOMPANIED BY A PLOT FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THINERGROUND STORAGE TANK REGULATIONS FORM B (6-95) FOROOS/B-RT