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• STATE OF CALIFORNIA a STATE WATER RESOURCES CONTROL BOARDUNDERGROUND 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 O 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE Yom' 8 TANK REMOVED T DBA OR FACILITY NAME WHERE TANK IS INSTALLED: - X�� ? CQ/ I. TANK DESCRIPTION COMPLETE ALL ITEMS– SPECIFY IF UNKNOWN A. OWNER'S TANK I.D.# B. MANUFACTURED BY: C. DATE INSTALLED(MOIDAYNEAR) 4 lam— D. TANK CAPACITY IN GALLONS: II.TANK CONTENTS IF A4 IS MARKED,COMPLETE ITEM C. A 1 MOTOR VEHICLE FUEL ❑ 4 OIL B.�I� � C. is REGULAR UNLEADED 3 DIESEL ❑ 6 AVIATION GAS -❑ 2 PETROLEUM ❑ 80 EMPTY �L'_]V PRODUCT lb PREMIUM UNLEADED 4 GASAHOL ❑ ] METHANOL ❑ 1c MKIGRADE UNLEADED ❑ 5 JET FUEL ❑ B M85 ❑ 3 CHEMICALPRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED ❑ 99 OTHER(DESCRIBE IN REM D.BELOW) D. IF(A1)IS NOT MARKED, ENTER NAME OFSUBSTANCE STORED C.A.S.#: 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 ❑ 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 W1 FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 C NCRETE ❑ 6 POLYVINYL CHLORIDE F-11 ALUMINUM E:] 8 100% METHANOL COMPATIBLE WIFRP (Primary Too) ❑ g BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER C.INTERIOR ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING LINING OR ❑ 5 GLASS LINING ❑ 6 UNLINED ❑ 95 UNKNOWN E] 99 OTHER COATING IS LINING MATERIAL COMPATIB ITH 10D% METHANOL? YES_ NO_ D.EXTERIOR ❑ 1 POLYETHYLENE WRAP ❑ COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC CORROSION PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE ❑95 UNKNOWN ❑ 99 OTHER E SPILL AND OVERFILL,etc. SPILL CONTAINMENT INSTALLED R) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) DROP TUBE YES_ NO_ STRIKER PLATE YES NO_ DISPENSER CONTAINMENT YES_ NO IV.PIPING INFORMATION CIRCLE AIFABOVE GROUND OR F 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 U 2 DOUBLE WALk, 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 3 POLYVINYL CHLORIDE(PVC)A U 4 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U ] STEEL W/COATING A U 8 100% METHANOL COMPATIBLE WIMP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION ,A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION 1 MEcwam LNE IFAK 2 IWE TlGxrxEss 3 CONNNUWS VfIFRSTIML CTNONIC UNE 5 AVIOW11C MW El DETECTOR I� 1ESTNG MOMTORMO N DETECTOR O 9N1DDWx ❑ 99 OTHEN V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 MANAL INVENTRECOONCILIATIONORV ❑ 3 MONIITORING VAOZE ❑ 4 GAUGING AUTOMATIC TANK ❑ 5 MONITORING R GROUND ❑6 ANNUALTESTING ❑ ] MON ITORING NG INTERSTITIAL ❑ 6 SIR ❑ 9 ANK GAUGINUAL ❑10 MOT HLY TANK ❑ 95 UNKNOWN ❑99 OTHER NG VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) 1.ESTIMATED DATE LAST USE701DAYNR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES T SUBSTANCE REMAINING —CLNO GALLONS INERT MATERIAL] O 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 (PAWED a SIGNATURE) LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION k FACILITY# TANK#00/ STATE I.D.# ja F a 3 f 9 PERMIT NUMBER PERMIT APPROVED SYAJATE PERMIT EXPIRATION DATE rE 6 /_ I Zvi THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORMA HAS BEEN FILED. FORM C MUST BE COMPLETED FOR IN ALLATIONS.THIS FORM SHOULD BE ACCOMPANIED BY A PLOT PI FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE"-"ERGROUND STORAGE TANK REGULATIONS FORM B (6-95) 1� '".0l FORUU34B111