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♦z STATE OF CALIFORNIA co' s STATE WATER RESOURCES CONTROL BOARD "�� "° ° UNDERGROUND STORAGE TANK PERMIT APPLICATION -FORM B i COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMITS CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ON SITE ONE REM ❑ 2 INTERIM PERMIT ❑ 6 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: I I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A OWNEWS TANK I.D.♦ B. MANUFACTURED BY: C. DATE INSTALLED(MOIDAY/YEAR) D. TANK CAPACITY IN GALLONS: 11.TANK t CONTENTS IF A-1 IS MARKED,COMPLETE ITEM C. A D�1. 1 MOTOR VEHICLE FUEL E] 4 OIL B. C. 1e AEGULAR UNLEADED ❑ 3 DIESEL ❑ 6 AVIATION GAS /'❑ 2 PETROLEUM ❑ 80 EMPTY 1 PRODUCT 1D PREMIUM UNLEADED ❑ 4 GASAHOL E] 7 METHANOL 1:1Ic MIDGRADE UNLEADED ❑ 5 JETFUEL [—] 8 M85 ❑ 3 CHEMICAL PRODUCT ❑ BS UNKNOWN 2 WASTE ❑ 2 LEADED ❑ 99 OTHER(DESCRIBE IN ITEM D.BELO'N) D. IF(A1)IS NOT MARKED. ENTER NAME OFSUBSTANCE STORED C.A.S.a: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.8,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 1 BARE STEEL ❑ 2 STAINLESS STEEL F—] 3 FIBERGLASS ❑ 4 STEEL CLAD N FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP (Primary Tank) ❑ 9 BRONZE ❑ /0 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER C.INTERIOR ❑ 1 RUBBER LINED �❑ 2 ALKYD LINING ❑ 3 EPDXY LINING E] 4 PHENOLIC LINING LINING OR ❑ 5 GLASS LINING n[I 6 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER COATING IS LINING MATERIAL COMPATIB WITH 100% METHANOL? YES_ NO 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,BTC. SPILL CONTAINMENT INSTALLED R) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) AVOr DROPTUBE YES_ NO STRIKER PLATE YES_ NO DISPENSER CONTAINMENT VES NO W.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IFUNDERGROUND,BOTH WAPPLICABLE A. SYSTEM TYPE AU 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION A 1 SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND A 1 BARESTEEL 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 STEELW/COATING A U B 100% METHANOL COMPATIBLE NFRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION ❑1 Lacx4NceL ME IEAIc ❑2 UNE 116MLESS ❑3 CDMNUWS INTERSTITML ❑4 EI MMM ME ❑5 AufO M W.- ❑ 99 DTIIER pETELfdI TE51N0 YONTd14l6 LEAs DETECT011 SNIm]DWN V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 MANUAL RECONCILIATIONNRY ❑ 3 VOZE MAODNIITORING E] 4 GAUGINGAUTOMATIC TANK E::]5 MROUND ON TORING�R ANNUALTANK ❑6 TESTING ❑ 7 CCOONTINNUR NUS INTERSTITIAL E::] 8 SIR ❑ 9 WEEKLY MANUAL ❑10 MOT�MLY TANK 5 UNKNOWN ❑99 OTHER MONITOG VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) 1.ESTIMATED DATE LAST USED(MC/DAY/YR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES ❑ NO SUBSTANCE REMAINING GALLONS INERTMATERIAL? 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 (PRINTED 6 SIGNATURE) —g' LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW Q Ci.J-IO COUNTY N JURISDICTION a FACILITY k7A—NK K STATE I.D.# D `6 °I D PERMIT NUMBER PERMIT APPROVED BY/DATE PER NT ATE D'I 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 INSTALLATION SHOULD BE ACCOMPANIED BY A PLOT " cILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING T' '--RGROUNDD STORAGE TANK REGULATIONS L FORME (6-95) 1`11