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STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD M1 UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B ° COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED ONSITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 8 TEMPORARY TANK CLOSURE 8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: aD s- Iv• I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A OWNER'S TANK I.D.R B. MANUFACTURED BY: 1 ♦� - C. DATE INSTALLED(MOIDAY/YEAR) `�' (,� (�. D. TANK CAPACITY IN GALLONS: QL, 0 /10A45 IL TANK CONTENTS IFA-1 IS MARKED,COMPLETE ITEM C. A, bg[ I MOTOR VEHICLE FUEL ❑ 4 OIL B. C. T-yT1C MOORADE UNLEADED 5 JETFUEL B MBS to REGULAR UNLEADED 3 DIESEL ❑ B AVIATION GAS ED 2 PETROLEUM 80 EMPTY 1 PRODUCT TLOb (g7 1a PREMIUM MILEAOED g 4 GASAHOL ❑ 7 METHANOL ❑ ❑ ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ ❑ ❑ 2 LEADED ❑ 99 OTHER PWRBENREM D.BELOWI D. IF(A1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A S III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A B.AND C.AND ALL THAT APPLIES IN BOX D ANO E A. TYPE OF I DOUBLE 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 ❑ I BARE STEEL ❑ 2 STAINLESS STEEL 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ B 10D% METHANOL COMPATIBLE W/FRP (Primary Tank) B BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER C.INTERIOR ❑ I RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING LINING OR ❑ 5 GLASS LINING ❑ 6 UNLINED f571 95 UNKNOWN ❑ 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO_ D.EXTERIOR ❑ I POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC CORROSION PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE 95 UNKNOWN ❑ 99 OTHER E.SPILL AND OVERFILL,BN:. SPILL CONTAINMENT INSTALLED(YEAR) r--OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) DROP TUBE YES_ NO_ STRIKER PLATE YES_ NO_ DISPENSER CONTNNMENT YES_ NO IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND.BOTH IF APPLICABLE A. SYSTEM TYPE A<0 I SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL U DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 9a OTHER C. MATERIAL AND A U 1 BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)AQ 4 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL W/COATING A U 8 100% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTIONI IEaaMai UQ ISAa 2 MIL mxn4ss c5rau5ua R TiIIIM. 4 ELEanpllt IMA Dunne Pur• ❑ ❑ BLTctTBR ❑ ns1NB ❑3 MaNraun ❑ rFM BETECIOR ED5 aNnOowx 99 onIER V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 MANUAL ANNUAL RECONCILIATION ❑ 3 MONITORING VADOZE ❑ 4 AUTOMAGAUGINGTIC TANK ❑5 MONITORING7GROUND � ❑B TESTINGTANK ❑ 7 CONTINUOUS INTERSTITIAL ❑ B SIR ❑ 9 WEEKLY TANK A MANUAL ❑10 TNTHLY TANK ❑ 95 UNKNOWN ❑99 OTHER VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) 1.ESTIMATED DATE MO/DAY/YR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH SUBSTANCE REMAINING GALLONS INERT MATERIAL 7 YES ❑ NO THIS FORAh HAS BEEN COMPLETED UNDER PENALTY OF PERJURYAAfD)TqTHA BEF OF MY KNOWLEDGE IS TRUE AND CORRECT TANK OWNER'S NAME (PRWTED a ImNATURE) \ DATE LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR N B S BELOW (aJ COUNTY# JURISDICTION A FACILITY 03C( TANK# STATE LD:# m = PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE 4 THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-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 PL 9LE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE' 'RGROUND STORAGE TANK REGULATIONS FORMS (6-95)