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STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B >r , I COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION O 7 PERMANENTLY CLOSED ON SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: / G46.OW I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A OWNER'S TANK I.D.# , B. MANUFACTURED BY: v C. DATE INSTALLED(MOIDAYIYEAR) D. TANK CAPACITY IN GALLONS: GJ IL TANK CONTENTS IF A-1 IS MARKED,COMPLETE ITEM C. A. M 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C. to REGULAR UNLEPDED 3 DIESEL ❑ 6 AVIATION GAS ❑ 2 PETROLEUM O 80 EMPTY �1 PRODUCT ❑ 1b PREMIUM UNLEADED 4 GASAHOL ❑ 7 METHANOL ❑ 1c MIDGRADE UNLEADED n�j 5 JET FUEL ❑ 8 M85 ❑ 3 CHEMICALPRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED u 99 OTHER(DESCRIBE IN ITEM D.BELOW) D. IF(Al)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 APPUES IN BOX D AND E A. TYPE OF [❑ 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER 1-15 INTERNAL BLADDER SYSTEM Q 95 UNKNOWN SYSTEM EN 2 SINGLE WALL ❑ 4 SINGLE WALL IN A VAULT ❑ 99 OTHER B. TANK ❑ 1 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 (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL 95 UNKNOWN ❑ 99 OTHER C.INTERIOR ❑ 1 RUBBER UNED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING LINING OR F-15 GLASS LINING O 6 UNLINED IN 95 UNKNOWN ❑ 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO— D.EXTERIOR O_D•EXTERIOR ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC CORROSION PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE cilz UNKNOWN 99 OTHER E.SPILL AND OVERFILL,eta 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 CA 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 A U 2 DOUBLE WALL A U 3 LINED TRENCH AE>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 6 CONCRETE A U 7 STEEL W/COATING A U 8 100% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED MEL A U 10 CATHODIC PROTECTION A(jr:A UNKNOWN A U 99 OTHER D. LEAK DETECTIONI NEONNa UNE LFAN 2 TWE tNNrxEss 3 CCN 14u wreraTmu 4 MMWC u s AImXMTw Ru9R ❑ GEIECTOR ❑ TESING MONGGRRNI LGN DETECTOR ❑ GNm00WN ❑ 99 OTHER V.TANK LEAK DETECTION �I�� ❑ C/ VISUAL CHECK 2 RECONCILIATION� UALINVENTORY [:] 3 MADOZERING ❑ 4 GAUGING AUTOMATIC AULNGC TANK ❑ 5 GROUND DINGTER 6 TESTNGTANK MONE:] 7 AC OONTINOUODUS INTERSTITIAL RING El SIR ❑ 9 WEEKLY MANGAL ❑10 MOTESTINGHLY 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❑ 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 (PmNTED b SIGNATURE? LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY M TANK# STATE I.D.# PERMIT NUMBER PERMIT APPROVED BYMATE PERMIT EXPIRATION DATE / THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. FORM C MUST BE COMPLETED FO STALLA ONS. THIS FORM SHOULD BE ACCOMPANIED BY A PLOT T -I'--HIS FORM WITH THE LOCAL AGENCY IMPLEMENTING TH' -RGROUND STORAGE TANK PIEGULATIONS FORM34GW