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STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD oM1 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 CSED ON SITE ONE REM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE ❑ B 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.# S B. MANUFACTURED BY: C. DATE INSTALLED(MODAWYEAR) "ns D. TANK CAPACITY IN GALLONS: �5 Q II.TANK CONTENTS IF A-/IS MARKED,COMPLETE ITEM C. A 1 MOTOR VEHICLE FUEL 4 OIL B. / C. -Fito REGU NLEADED 3 DIESEL 6 AVIATION GAS ❑ 2 PETROLEUM ❑ 80 EMPTY R I 1 PRODUCT b PRE M UNLEADED 4 GASAHOL ❑ 7 METHANOL ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN '❑�2 WASTE ❑ 1C EUNLEADED O 5 JETFUEL ❑ 8 MSS ❑ DED ❑ 99 OTHER(DESCRIBE IN ITEM D.BELOW) D. IF(A1)IS NOT MARKED, ENTER N E OF SUBSTANCE STORED C.A S.R: III. TANK CONSTRUCTION K ONE ITEM ONLY IN BOXES A.B.AND C.AND ALL THAT UES IN BOX D AND E A. TYPE OF ❑ 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR ER ❑ 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 ❑ 8 100% METHANOL COMPATIBLE W/FRP (NmryTMIQ ❑ 9 BRONZE ❑ 10 GALVANIZED STEE ❑ 95 UNKNOWN ❑ 99 OTHER C.INTERIOR ❑ 1 RUBBER LINED 2 ALKYD UN ING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING LINING OR ❑ 5 GLASS UNING 6 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WI 100% METH OL? YES_ NO— D.EXTERIOR ❑ 1 POLYETHYLENE WRAP ❑ 2 OATN ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC CORROSION PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 N ❑95 UNKNOWN ❑ 99 OTHER E.SPILL AND OVERFILL,SIC. SPILL CONTAINMENT INSTALLED(Y ) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) DROP TUBE YES_ NO STRIKERPLATE YES NO DISPENSER CONTAINMENT YES_ NO_ IV.PIPING INFORMATION CIRCLE A IFASOVE ROUND U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION 2 PRESS E A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL A U 2 DOUBLE LL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND A U 1 BARE STEEL A U2 STAINLESS%ELA U 3POLYVINYL CHLORIDE(PVC)A U 4 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U S CONCRETEA U 7 STEELW/COATING A U 8 100% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED EL A U 10 CATHODIC CTION A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION4 E I AECPAMCN LINE 2 UNE TKJR N 3 WIEAST IPMMIC UNE UIGMATC DUAP O ❑ I!EiEGTOR TE511N3 YOMTQ31 IFAN OEIECfON ❑5 ASNUf0G1YN 99 OTHER V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK 2 MANUAL RECONCILIATION MONITORING ❑ 3 MONIITORING OZE ❑ 4 GAUGING AUTOMATIC TANK ❑5 MON MONITOOUND RING ❑ S TESTINGANNUAL ❑ 7 MONITORINGINTERSTITIAL S SIR ❑ 9 WEEKLY MANUA ❑ 10 MONTHLY TANK ❑ 95 UNKNOWN ❑99 OTHER TESTING VI.TANK CLOSURE INFO ATION(PERMANENT CLOSURE IN-PLACE) 1.ESTIMATED DATE LAST USED O/DAWYR) 2.ESTIMATED OUANTTY OF 3.WAS TANK FILLED WITH SUBSTANCE REMAINING ALLONS INERT MATERIAL 7 YES ❑ NO❑ THIS FORM HAS SON COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT TANK OWNER'S NAME DATE IPRWN d SIGNATURE) LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY# .:37(P TANK# p STATE I.D:# m 3 I o ILF 0 PERMIT NUMBER PERMIT APPROVED BY/DATE PERMT EXPIRATION DATE THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORMA HAS BEEN FILED. FORM C MUST BE COMPLETED FOR INSTALLATIONS. THIS FORM SHOULD BE�A`CCCOOM��PANNIJIEEDDBBBY A PLOT PLAN "LE THIISSFORM /yWITH TTHE�LLOOCAL AGENCY IMPLEMENTING THE UN^-9GROUND STORAGE TANK REGULATIONS NORM (6-95) W- J 1 L(/c/�-C- �� { 1 V 71. 1 Y7T 719V