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• STATE OF CALIFORNIA • ^`" e`q STATE WATER RESOURCES CONTROL BOARD o UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B �I µ i COMPLETE A SEPARATE FORM FOR!!PH TANK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ ] PERMANENTLY CLOSED ONSITE ONE REM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: I. TANK DESCRIPTION COMPLETE ALL ITEMS– SPECIFY IF UNKNOWN A OWNER'S TANK I.D.X D B. MANUFACTURED BY: , ! k C. DATE INSTALLED(MO/DAY/YEAR) D. TANK CAPACITY IN GALLONS:�v II.TANK CONTENTS IFA-1 IS MARKED,COMPLETE ITEM C. A 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C. 111a REGULAR UNLEADED 3 DIESEL ❑ 6 AVIATION GAS ❑ 2 PETROLEUM ❑ 80 EMPTY 1 PRODUCT ❑ 1b PREMIUM UNLEADED ❑ 4 GASAHOL ❑ ] METHANOL ❑ 3 CHEMICAL PRODUCT ❑ BS UNKNOWN 2 WASTE ❑ lc MIDGRADE UNLEADED ❑ 5 JET FUEL ❑ 8 M85 ❑ 2 LEADED ❑ 99 OTHER(DESCRIBE IN REM D.BELOW) D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S.X 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 BLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 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 ggAqFIIEBEEERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL r75 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ MINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP (Primary Tank) ❑ g BRONZE ❑ 10 GALVANIZED STEEL 95 UNKNOWN ❑ 99 OTHER C.INTERIOR ❑ 1 RUBBER UNED ❑ 2 ALKYD LINING ❑ 3EP XY UNING ❑ 4 PHENOLIC LINING LINING OR F—] 5 GLASS LINING F—] 6 UNUNED 5 UNKNOWN ❑ 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 100°,6 METHANOL? YES_ NO_ D.EXTERIOR ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 L WRAP ❑ d FIBERGLASS REINFORCED PLASTIC CORROSION PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE 95 UNKNOWN ❑ 99 OTHER E.SPILL AND OVERFILL,BSC. SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) DROP TUBE YES_ NO_ STRIKERPLATE 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 ACU> 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 CONCRETE A U ] S EL W/COATING A U 8 100% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL 10 CATHODIC PROTECTION A 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION 1 MSG ICPL UNE 1. 2 UNE nG.. 3 oaNml.a... d ELECiRONIG UNE 5 wroMAnc wNw ❑ DETECTOR TESnNG ❑ WWWING 1:1LEAK=CTOR ❑ SN=WnMC ❑ 99 OTHER V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK Ell'2 RECO CILIATIONNUAL ORV [:] 3 MONITORING VADOZE ❑ d GAUGING AUTOMATIC TANK ❑5 MONITORINGGROUND TER 6 TESTINGTANK ❑ T CONTINUMONITORU INTERSTITIAL El SIR 119 WEEK GAUGING ❑ 10 MOSNTHLY TING TANK ❑ 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PUCE) 1.ESTIMATED DATE LAST USED(MO/DAY/YR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES ❑ NO E::]SUBSTANCE 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 d SIGNATORE) LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION N FACILITY# TANK# STATE I.D.# FZq 6 2 5 PERMIT NUMBED PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLIC TION-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. FORM C MUST BE COMPLETED FOR INSTALL TIONS. THIS FORM FORM B (6-95) SHOULD BE ACCOMPANIED BY A PLOT POFILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THIERGROUND STORAGE TANK REGULATIONS FOROONB-R]