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STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD ...... UNDERGROUND STORAGE TANK PERMIT APPLICATION-FORM B W COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. `'��_�•" o MARK ONLY 1 NEW PERMIT ❑ 3 RENEWAL PERMIT E]ONE REM El 2 INTERIM PERMIT ❑ 5 CHANGE OF INFORMATION ❑ ] PERMANENTLY CLOSED ON SITE 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE B TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: I. TANK DESCRIPTIONCOMPLETE ALL ITEMS– SPECIFY IF UNKNOWN \ A OWNER'S TANK I.D.i S. MANUFACTURED BY: G DATE INSTALLED(MO/DAY/YEAR) D. TANK CAPACITY IN GALLONS: I II.TANK CONTENTS IFA-I IS MARKED,COMPLETE ITEM C. A ❑ 1 MOTOR VEHICLE FUEL ❑ 4 OIL B C. ❑ la❑ PEGULAR UNLEADED 3 DIESEL 6 AVIATION GAS 2 PETROLEUM 80 EMPTY �1 PRODUCT ❑ 1b PREMIUM UNLEADED ❑ 4 GASAHOL ❑ 7 METHANOL ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 yypS-TE ❑ Ic MIDGRADE UNLEADED ❑ 5 JETFUEL ❑ 8 M85 D. IF(A 1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED ❑ 2 LEADED ❑ 99 OTHER(DESCRIBE IN REM D.BELOlS� III. TANK CONS T R UCTION MARK ONE ITEM ONLY IN BOXES A.B,AND C,AND ALL THAT APPLIES IN BOX D AND E C.A S.#; A. TYPE OF 'L_SI I DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER SYSTEM ❑ 2 SINGLE WALL ❑ ❑ 5 INTERNAL BLADDER SYSTEM ❑ 95 UNW40WN 4 SINGLE WALL IN A VAULT ❑ 99 OTHER B. TANK ❑ I BARE STEEL ❑ 2 STAINLESS STEEL MATERIAL � 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC ❑ 5 CONCRETE O 6 POLYVINYL CHLORIDE 7 ALUMINUM (P*"Y") ❑ 9 BRONZE ❑ ❑ 8 1METHANOL COMPATIBLE W/FRp ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN O OTHER 99 OTHER C.INTERIOR ❑ I RUBBER LINED ❑ 2 ALKYD LINING ❑ LINING OR 3 EPDXY UNING ❑ 4 PHENOLIC LINING 5 GLASS LINING ❑ 6 UNLINED COATING ❑ 95 UNKNOWN ❑ 99 OTHER IS LINING MATERIAL COMPATIBLE WITH IOD% METHANOL? YES NO_ D.EXTERIOR EDP ❑ 2 COATING I POLYETHYLENE WRAP ❑ 3 VINYL WRAP ^� 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ED5 CATHODIC PROTECTION [—] 91 NONE ❑95 UNKNOWN 99 OTHER ❑ E.SPILL AND OVERFILL,BI0. SPILL CONTAINMEN IN TALLED(YEAR) OVERFILL PREVENRON EQUIPMENT INSTALLED(YEAR) DROP TUBE YES NO_ STRIKER PLATE VES NO_ IV, PIPING INFORMATION CIRCLE A IFABOVEGROUND OR U IF UNDERGROUND,BOTH IF APPLICABLE DISPENSER CONTAINMENT YES_ NO A. SYSTEM TYPE A U 1 SUCTION U PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING q U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL f7UD 2 DOUBLE WALL A U 3 LINED TRENCH p U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND A U 1 BARE STEEL A U 2 STAINLESS STEEL p U 3 POLYVINYL CHLORIDE(PVC) 4 CORROSION A U S ALUMINUM A U 8 CONCRETE FIBERGLASS PIPE PROTECTION A U7 STEEL W/COATING A U 8 100% METHANOL COMPATIBLE W/FRP 9 GALVANIZED STEEL p U 10 CATHODIC PROTECTION D. LEAK DETECTION ❑ ii Z; O ❑2 uNE TXJRNE55 3 A U 95 UNKNOWN A U 99 OTHER_ t IECNNOG4 ZINE IFAI( GGN "s N1ER5T1 FD 1 BECIRGNIC uNE��TS AUfOM1nG NYP TEslaq IMMTGAING sFAN OETECfOR JAL 91Un1GWN ❑ 99 OTHER V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 MANUAL INVENTORY ❑ 3 VADOZE fXt q AUTOMATIC TANK 5 GROUND WATER 6 ANNUAL TANK 7 CONTINUOUS INTERSTITIAL RECONCILIATION MONITOgING r r GAUGING ❑ MONITORING ❑ 8 SIR ❑ 9 WEEKLY MANUAL ❑ 10 MONTHLY TANK MONITORING ❑ TESTING TANK GAUGING TESTING ❑ 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) 1.ESTIMATED DATE LAST USED(MO/DAY/VR) 2.ESTIMATED QUANTITY OF SUBSTANCE REMAINING3.WAS TANK FILLED WITH ❑ THlS FORM HAS BEEN COM LETED UNDER PENAL 7-Y GALLONS INERTMATERIAL7 YES ❑ NO Y OF PERJU TANK OWNER'S N ,AND TO B (PRW 6SKiNATURE)AME T EDGE, IS TRUE AND CORRECT �Ya - DA LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR OW STATE I.D:# COmp JURISDICTION�p FACILITY COC? TANK A 00.5 PERMIT NUMBER PERMIT APPROVED BYA7ATE PERMIT EXPIRATION DATE THIS FOgM MUST BE ACCOMPANIED AL jIA PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. FORM C MUST BE COMPLETED FO q I U IONS. THIS FOR S M SHOULD BE ACCOMPANIED BY A PLOT P�FlLE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THERGROUND STORAGE TANK REGULATIONS B (6.95)