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` STATE OF CALIFORNIA URC, STATE WATER RESOURCES CONTROL BOARD o UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ]C 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED O SITE ONE ITEM IL�J1 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK '1707D D DBA OR FACILITY NAME WHERE TANK IS INSTALLED: I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A OWNER'S TANK L D.# B. MANUFACTURED BY: C. DATE INSTALLED(MO/DAY/YEAR) D. TANK CAPACITY IN GALLONS: `v�-•V II.TANK CONTENTS IF A-1 IS MARKED,COMPLETE ITEM C. A 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C. ❑ 1a REGULAR UNLEADED ❑ 3 DIESEL ❑ 6 AVIATION GAS 2 PETROLEUM ❑ 80 EMPTY 1 PRODUCT ❑ ib PREMIUM UNLEADED ❑ 4 GASAHOL ❑ 7 METHANOL 1C MIDGRADE UNLEADED ❑ 5 JETFUEL ❑ 8 M85 ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN .❑ 2 WASTE 2 LEADED ❑ 99 OTHER(DESCRIBE IN ITEM D.BELOW) D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE 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 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 ❑ 3 FIBERGLASS IQI 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM 7❑ 8 100% METHANOL COMPATIBLE W/FRP (Primary Tank) ❑ 9 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 ❑ 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO_ ,.�...,/ D'EXTERIOR F-11 POLYETHYLENE WRAP L] 2 COATING ❑ 3 VINYL WRAP YI 4 FIBERGLASS REINFORCED PLASTIC CORROSION PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE trn ❑ 95 UNKNOWN ❑ 99 OTHER omil- E.SPILL AND OVERFILL,810. SPILL CONTAINMEALLED(YEAR) OVERFI EVENTION EQUIPMENT INSTALLED(YEAR) DROP TUBE YES INSTNO_ p KER PLATE YES NO DISPENSER CONTAINMENT ES 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 A&2DOUBLE WALL A 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 A U 3 POLYVINYL CHLORIDE(PVC) 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 ❑1 MECIWAO L UNE LEAK 2 UNE TIGMNESS ❑3 OWINUOUS IMERS9nAL ❑4 ELEMONIC LINE ❑5 AUrOMAnC PUMP CETECTOR TE511NG MOMTORING LEAK DETECTOR SHOMM ❑ 99 OTHER V.TANK LEAK DETECTION - y U �✓ ❑ 1 VISUAL CHECK 11 2 MANUALIRECONCILILATIONORY ❑ 3 VADOZE MONITORING ❑ 4 AUTOMATGAUGING MONITORING TANK ❑ 5 GROUND MONTORINGTER ❑ 8 ANNUALTESTING T CONTINUOUS MONITORING INTERSTITIAL ❑ 8 SIR ❑ 9 WEEKLY MANUAL ❑10 MONTHLY TANK ❑ 95 UNKNOWN 99 OTHER TANK GAUGING TESTING ❑ 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 SUBSTANCE REMAINING GALLONS INERT MATERIAL?,�,. YES ❑ NO ❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT TANK OWNER'S NAME �-y (PRINTED 4 SIGNATURE( r(/ DATE LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW STATE LD:# COUNTY# JURISDICTION# FACILITY# ,Y�, TANK*' C PERMIT NUMBER PERMIT APPROVED BV/DATE PERMIT E%PIRATION UATE THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLI N•FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. FC MUST BE COMPLETED FOR INSTALLATIONS. THIS FORM SHOULD BE ACCOMPANIED BY A PLOT PILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING TH RGROUND STORAGE TANK REGULATIONS FORM a (6-95) - i,;1