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• STATE OFCAUFORNIA • STATE WATER RESOURCES CONTROL BOARD i` 'e,W •,act o 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 E] 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED 7l� DBA OR FACILITY NAME WHERE TANK IS INSTALLED: V I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN (p A OWNER'S TANK I.D.A B. MANUFACTURED BY: �V C. DATE INSTALLED(MO/DAYNEAR) D. TANK CAPACITY IN GALLONS: II.TANK CONTENTS IFA-1 IS MARKED,COMPLETE ITEM C. A ❑ 1 MOTOR VEHICLE FUEL ❑ 4 OIL S. C. ❑ to REGULAR UNLEADED ❑ 3 DIESEL ❑ 8 AVIATION GAS ❑ 2 PETROLEUM 2r80 EMPTY PRODUCT ❑ iL PREMIUM UNLEADED ❑ 4 GASAHOL ❑ 7 METHANOL ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 1c MDGRADE UNLEADED 5 JET FUEL ❑ 8 M85 ❑ 2 LEADED 99 OTHER(DESCRIBE IN ITEM D.BELOM D. IF(A1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A S.M: 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 Ibl 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 ❑ 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 (PdnNq T-k) ❑ 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 rKr,,7,r 5 GLASS LINING ❑ 8 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES- . NO_ D CO ERIORN ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING E:] 3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODICPROTECTiON ❑ 91 NONE ❑95 UNKNOWN ❑ 99 OTHER E.SPILL AND OVERFILL,HNC. SPILL CONTAINME T STALLED(YEAR) OVER PREVENTION EQUIPMENT INSTALLED(YEAR) DROPTUBE 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 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 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 ZiIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL W/COATING A U 8 100% METHANOL COMPATIBLEWIFRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION ❑1 MECNIHICAL IME LFAN ❑2 Mk TIGN1M1E55 3 CON9NUW5 IMEA511RU 4 ELELiRCNIt NHE 5 AU101M9L PUMP LLIECfOR TESTING M NUW S ❑ EUCGETECiUR AMOMATC ❑ 99 OVER V.TANK LEAK DETECTION �7❑ 1 VISUAL CHECK ❑ 2 gECONCIUATNUAL EONORY ❑ 3 VADOZE MONITORING 4 GAUGING C TANK ❑5 MONITORING WATER ❑ 6 TTESTINGTANK 'P--'- 7 MON TOR NUU INTERSTITIAL ❑ 8 SIR ❑ 9 WEEK LY MANUAL E] 10 MOTESTINGHLY TANK E] 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) 1.ESTIMATED DATE LAST USED(MO/DAY/YR) 2.ESTIMATED QUANTITY OF 3.W;NOWLED(GE TANK FILLED WITH YES ❑ NO ❑ S STANCE EMAINING GALLONS NERT MATERIAL 7 LET J Y,A T F ,ISTRUEAND CORRECT TANK OWNER'S NAM AE / (PRINTE)6 NEESIGNATURE) LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPO D F MBERS BELOW COUNTY# JURISDICTION# FACILITY# TANK OD STATE ILD:# m 2T3-I 09 ' Ead alk. IL 11 PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE /Z Z TAT] 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 IN ALLATIONS.THIS FORM SHOULD BE ACCOMPANIED BY A PLOT P' LE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE RGROUND STORAGE TANK REGULATIONS FORMS (6-95)