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STATE OF CALIFORNIA J STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM B 1 COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED O ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A OWNER'S TANK I.D.N / B. MANUFACTURED BY: C. DATE INSTALLED(MCIDAYNEAR) D. TANK CAPACITY IN GALLONS: 11.TANK CONTENTS IFA-1 IS MARKED,COMPLETE ITEM C. A, JW1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C. to REGULAR UNLEADED ❑ 3 DIESEL ❑ 6 AVIATIONGAS ❑ 80 EMPTY ❑ 1 PRODUCT ❑ 1b PREMNM UNLEADED ❑ 4 GASAHOL ❑ 7 METHANOL 2 PETROLEUM ❑ 1c MIDGRADE UNLEADED 5 JETFUEL ❑ 8 M85 ❑ 3 CHEMICALPRODUCT 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED 99 OTHER(OESCRIBEIN ITEM O.BELOW) D. IF(A7)IS NOT MARKED. ENTER NAME OF SUBSTANCE STORED C.A.S.R: 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 ( 2 SINGLE WALL ❑ 4 SINGLE WALL IN A VAULT ❑ 99 OTHER B. TANK ,JCI. I 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 ❑ I RUBBER LINED �❑ 2 ALKYD LINING F—] 3 EPDXY UNING ❑ 4 PHENOLIC LINING LINING OR ❑ 5 GLASS LINING 1 l 8 UNUNED ❑ 95 UNKNOWN ❑ 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 700% METHANOL? YES_ NO-K D.EXTERIOR ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC CORROSION PROTECTION ❑ 5 CATHODIC PROTECTION X 91 NONE ❑95 UNKNOWN ❑ 99 OTHER E.SPILL AND OVERFILL,73IC. SPILLCONTAINMENT INSTALLS R) OVERFILL PREVENTI N OUIPMENT INSTALLED(YEAH) DROP TUBE VES_ 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 FLEXIBLEPIPING A099 99 OTHER B. CONSTRUCTION A& SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A95 UNKNOWN A U 99 OTHER C. MATERIAL AND AG)l 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 STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION [:]I MiCHM4CAL UNE IF.1K 2 NNE TMN M 3 CpnlMldl3 INTERSRnAL 4 MECIRCNIC UNE 5 AUfGMA9C PUMP 0E1ECmR ❑ TES ❑ MCNfOBNIG ❑ LFAN OEIEOTMI ❑ 9a "C 99 OTHER AIA A�- V.TANK LEAK DETECTION ❑ 7 VISUAL CHECK ❑ 2 MANUAL RECONCILIATION MONITORING ❑ 3 VADOZE MONITORING ❑ 4 AUTOMATGAUGING MONITORING TANK ❑ 5 GROUND MONTORINGTER E::] ANNUALTANK 8 TESTING ❑ 7 MON TOR U INTERSTITIAL ❑ 8 SIR ❑ 9 WEEKGAUGINGAL ❑/0 MOT HLY TANK NG 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.WAS TANK FILLED WITH YES ❑ NO T�[q SUBSTANCE REMAINING GALLONS INERT MATERIAL? 7`1 THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT TANK OWNERS NAME DATE (PRINTED d SIGNATURE) LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW L' ' COUNTY N JURISDICTION# FACILITY a()() 3 STATE ILD.# PERMIT NUMBER PERMIT APPROVED BYIDATE PERMIT EXPI 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 PLO- "LE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING T "'-PRGROUND STORAGE TANK REEGGUUL�A//�TI I�',/_.jw_ FORME (6-95)SHOULD �— 9� . /�i (+I(//