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4" STATE OF CAUFORNIA �•'.....; STATE WATER RESOURCES CONTROL BOARD 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 ON SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ < AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE I1 B TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: 4� I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A OWNERS TANK 1.0.f 7519_ _ mi B. MANUFACTURED BY: C. DATE INSTALLED(MODAYNEAR) 73 D. TANK CAPACITY IN GALLONS: II.TANK CONTENTS IF A-1 IS MARKED,COMPLETE ITEM C. A &1 MOTOR VEHICLE FUEL ❑ 4 OIL B. p_ 1a:REP�UNLEPDm 3 DIESEL ❑ 8 AVIATION GAS 2 PETROLEUM ❑ 80 EMPTY E&1 PRODUCT LL11S UM ULEADED g C GA$pHOL ❑ 7 METHANOL 3 CHEMICALPRODUCT ❑ BS UNKNOWN ❑ 2 WASTE to ADE UNLEADED ❑ 5 JET FUEL ❑ 8 M85 ❑ 2 ED ❑ gg OTHER(DESCRIBE M REM D.BELOWO D. IF(XI)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A S.f: ill. 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 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 5 INTERNAL BLADDER SYSTEM ❑ 95 UNKNOWN SYSTEM �11 2 SINGLE WALL ❑ ! SINGLE WALL IN A VAULT ❑ 99 OTHER B. TANK IJ 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 0 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ B 100% METHANOL COMPATIBLE W/FRP (PTImwy Tok) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER C.INTERIOR ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ C PHENOUC LINING LINING OR ❑ 5 GLASS LINING EX 6 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO— D.EXTERIOR ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ 6 FIBERGLASS REINFORCED PLASTIC CORROSION PROTECTION ❑ 5 CATHODIC PROTECTION EX 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER E SPILL AND OVERFILL,BLC. 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 A U 1 SUCTION 2 PRESSURE A U 3 GRAVITY A U d FLEXIBLEPIPING A U 99 OTHER B. CONSTRUCTION A U 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(9 1 BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A U 0 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U B 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 DETECTION1 1EgON1�uL IFuc z Lei TMHrwee 3 ca"wu°e°'"re^s"Ru '''''''TI LLccmaac urrE urownc Puw ❑ 9ETECNOA ❑ TESRNi I� IIaMTa9sN9 IJ ff.Vt OEIECTOR O 5 A9AIT C ❑ 99 OTTER V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 MANUAL RECONCINVENTORY ❑ 3 MO�ZORING ❑ + GAUGING TANK ❑ 5 GROUND WATER ❑6 ANNUALTANK ❑ 7 TESTING MONITORINGNUOUS INTERSTITIAL. ❑ 8 SIR ❑ 9 WEEKLY MANUAL ❑10 MONTHLY TANK ❑ 95 UNKNOWN ❑ 99 OTHER TANK GA MNG TESTING 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 ❑ SUBSTANCE REMAINING GALLONS INERT MATERIAL 7 THIS FORM HAS BEEN C E UNDER PENALTY OF PERJURY,ANO TO THE B MY KNOWLEDGE,IS TRUEND CORRECT TANK OWNER'S NAM pA7E (PRINTEDA EN'S RE) LOCAL AGENCY USE ONLY THE STATE I.D.NUM6646 COMPOSED 0 E FOUR NUMBERS BELOW COUNTY M JURISDICTION k FACILITY k TANK M STATE 04 m 0 13 PERMIT NUMBER PERMIT APPROVED BYITJATE PERMIT EXPIRATION DATE ` ,) l� 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 PLAN. FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS FORMS (695)