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STATE OF CALIFORNIA ^`so ,., STATE WATER RESOURCES CONTROL BOARD xy coM1'o UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B r �: COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ONSITE ONE REM ❑ 2 INTERIM PERMIT O 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED C / DBA OR FACILITY NAME WHERE TANK IS INSTALLED: I. TANK DESCRIPTION COMPLETE ALL ITEMS— SPECIFY IF UNKNOWN A OWNER'S TANK I.D.p B. MANUFACTURED BY: C. DATE INSTALLED(MC/DAY/YEAR) D. TANK CAPACITY IN GALLONS: I Z CLO ✓ II.TANK CONTENTS IF A-1 IS MARKED,COMPLETE ITEM C. A 4-n MOTOR VEHICLE FUEL ❑ 4 OIL B.,I--� C. IS REGULAR UNLEADED O 3 DIESEL ❑ 6 AVIATIONGAS 7❑ 2 PETROLEUM ❑ BO EMPTY 1 PRODUCT 1b PREMIUM UNLEADED ❑ 4 GASAHOL ❑ 7 METHANOL O 3 CHEMICALPRODUCT ❑ 95 UNKNOWN /❑ 2 WASTE ❑ 1C MIDGRADE UNLEADED ❑ 5 JETFUEL ❑ 8 MBS ❑ 2 LEADED O 99 OTHER(DESCRIBE IN ITEM D.BELOW) D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S.p: 111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.B,AND C.AND ALL THAT APPLIES IN BOX D AND A. TYPE OF E4, 1 DOUBLE WALL O 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 O 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP (Primary Tank) ❑ 9 BRONZE O 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER C.INTERIOR ❑ 1 RUBBER UNED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING 4 PHENOLIC LINING LINING OR ❑ 5 GLASS LINING ❑ 6 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 10096 METHANOL? YES_ NO— D.EXTERIORF-11 POLYETHYLENE WRAP O 2 COATING ❑ 3 VINYL WflAP 4 FIBERGLASS REINFORCED PLASTIC CORROSION PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE 95 UNKNOWN ❑ 99 OTHER E.SPILL AND OVERFILL,ltC. SPILL CONTAINMENTJNSTALLED(YEAR) OVERSPREVENTION EQUIPMENT INSTALLED(YEAR) DROPTUBE YES NO STRIKER PLATE YES NO_ DISPENSER CONTAINMENT YES NO IV.PIPING INFORMATION CIRCLE A IFABOVEGROUNDOR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION A 2 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL <02 WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIALAND A U 1 BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)AQ4 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 [:]1 6ffC K&LINE LEEW 2 UNE 9GWNESS ❑3=MNUD'JS R ERSi ❑4 ELECTRONIC UNE O 5 SM AUrOWTIC PUMP ❑ DEMMOR TESTING MONITWING LEAN M EMR rD 99 OTHER V.TANK LEAK DETECTION W erj t4MNIC. {P r/!/E -r Z>l,, ❑ 1 VISUAL CHECK ❑ 2 MANUAL)INVENTORY ❑ 3 MONOITORING ❑ 4 AUTOGAUGMATICTANK ❑5 MONITORING DWATER �ANNUJEAL 7MON TOR NG NUOUS INTERSTITIAL ❑ B SIR ❑ 9 TWEEKLY ANKGAUGANGAL ❑10 TIESTNGyTANK O 95 UNKNOWN VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) 1.ESTIMATED DATE LAST USED(MO/DAYNR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES ❑ NO SUBSTANCE REMAINING GALLONS INERT MATERIAL 7 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) LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION N FACILITY N TANK N STATE LD:# mLA31 /I d s" b (o PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE 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 PLOT PORLE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING TH7fRGROUND STORAGE TANK REGULATIONS FORMS (6-95)