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STATE OF CALIFORNIA +, STATE WATER RESOURCES CONTROL BOARD �< ° UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B "�� =° COMPLETE A SEPARATE FORM FOR!A WANK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT EK 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSEDN�SITE ONE REM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT E] 6 TEMPORARY TANK CLOSURE ED TANK REMOVED /c 1- l t ' DBA OR FACILITY NAME WHERE TANK IS INSTALLED: 54- C �p I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A OWNER'S TANK I.D.# B. MANUFACTURED BY: C. DATE INSTALLED(MO/DAYNEAR) D. TANK CAPACITY IN GALLONS: II.TANK 900ENTS IF A-1 IS MARKED,COMPLETE ITEM C. A [Frl MOTOR VEHICLE FUEL ❑ 4 OIL B. Eo C. ❑ 1# RE"UNLEADED ❑ 3 DIESEL ❑ 6 AVIATION GAS ❑ 2 PETROLEUM ❑ 80 EMPTY 1 PRODUCT ❑ 1 MIUM UNLEADED ❑ 4 GASAHOL ❑ 7 METHANOL 1C MIDGRADE UNLEADED ❑ 5 JET FUEL ❑ 8 M85 ❑ 3 CHEMICALPRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED ❑ 99 OTHER(DESCRIBE IN ITEM 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 UBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 5 INTERNAL BLADDER SYSTEM E-] 95 UNKNOWN SYSTEM 2 SINGLE WALL ❑ 4 SINGLE WALL IN A VAULT ❑ 99 OTHER B. TANK ❑ 1 BARE STEEL ❑ 2 STAINLESSSTEEL ❑ 3 FIRE SS E] 4 STEEL CLAD Wl FIBERGLASS REINFORCED PLASTIC MATERIAL F-15 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ ] UMINUM E::] B IW% METHANOL COMPATIBLE W/FRP (PHm9TY T#Rk) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL 95 UNKNOWN ❑ 99 OTHER C.INTERIOR ❑ 1 RUBBER UNED ❑ 2 ALKYD LINING ❑ 3 OXY LINING ❑ 4 PHENOLIC LINING LINING OR ❑ 5 GLASS UNING ❑ 6 UNLINED 5all's UNKNOWN ❑ 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES— NO_ D.EXTERIOR ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 WRAP ❑ d FIBERGLASS REINFORCED PLASTIC CORROSION PROTECTION ❑ 5 CATHODIC PROTECTION [:j91 NONE 95 UNKNOWN ❑ 99 OTHER E.SPILL AND OVERFILL,BIC. 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 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 2 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 COMPATIBLE WIFRP PROTECTION A U 9 GALVANIZED STEEL 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION ❑1 MECNINCAL UN IE LFN( 2 UNE M NESS 3 CG NUWS INfERSTIfIAI 4 ELECTRCMC LINE 5 AaIATIC PUMP DETI=A TESTING ❑ WWMING LEAK DETECTCIL ❑ mlf m ❑ 99 OTHER V.TANK LEAK DETECTION ❑ 1 VISUAL CHECKMANUAL 2 RECONCILIATIONORV E] 3 VAOZE MONIITORING ❑ 4 AUTOMAXGAUGING MONITORING TANK ❑ EZ' TAN 5 MONTORINGTER 8 TESTING K ❑ 7 MONITOR U INTERSTITIAL ❑ 8 SIR ❑ 9 TANK LY MANUAL ❑ 10 MOTESTING_HLY TANK ❑ 95 UNKNOWN E]99 OTHER VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PUCE) 1.ESTIMATED DATE LAST USED(MO/DAYNR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES [:j NO❑ SUBSTANCE REMAINING GALLONS INERTMATERIAL9 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 It FACILITY# TANK If STATE I.D.# ff p PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE - j THIS FORM MUST BE ACCOMPANIED BY A PERMIT APP LI ION-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 WILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THorRGROUND STORAGE TANK REGULATIONS FORM B (G95) FOR0014B117