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STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B tl° `Iv+ 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 ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED OBA OR FACILITY NAME WHERE TANK IS INSTALLED: I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN f A. OWNER'S TANK I.D.# S. MANUFACTURED BY: Irl N C. DATE INSTALLED(MO/DAY/YEAR) _ -'j D. TANK CAPACITY IN GALLONS; II.TANK CONTENTS IFA-1 IS MARKED.COMPLETE ITEM C. A ISI I9 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C. ® to REGULAR UNLEADED ❑ 3 DIESEL ❑ 6 AVIATION GAS o tb PREMIUM UNLEADED ❑ 4 GASAHOL ❑ 7 METHANOL r—] 2 PETROLEUM ❑ 80 EMPTY 1 PRODUCT ❑ 1c MIDGRADE UNLEADED ❑ 5 JETFUEL ❑ 8 M85 ❑ 3 CHEMICALPRODUCT ❑ 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.8,AND C.AND ALL THAT APPLIES IN BOX D AND E A. TYPE OF Is 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 ❑ I BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ® 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ B 100% METHANOL COMPATIBLE W/FRP (Primary Tank) 9 BRONZE ❑ 10 GALVANIZED STEELL❑ 95 UNKNOWN ❑ 99 OTHER C.INTERIOR F-1I RUBBER LINED ❑ 2 ALKYD LINING 3 EPDXY UNING ❑ 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.EXTERIOR ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC CORROSION91 NONE E] 95 UNKNOWN � 99 OTHER PROTECTION ❑ s CATHODIC PROTECTION ❑ SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(NEAR) E.SPILL AND OVERFILL,BTC. DROP TUBE YES NO_ ST 11 ER 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 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 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)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. NECRN l UNE LEAK 2 LINE TIGHTNESS 3 C INUWS INTERSTRIAl 4 ELECTRONIC UAE O 5 AIRCM4IIC PUNA ❑ 99 OTHER D. LEAK DETECTION ❑ DEMMOR TESTING ❑ NONmI Na ❑ LEAK DEIECTCR sxuroowN V.TANK LEAK DETECTION W .0 ( ITS fir~ 5 I uT ❑ I VISUAL CHECK ❑ 2 RECONCILIATIONMANUAL ORY ❑ 3 MONITORING '!�4 AUTOMATGAUGING IC TANK ❑ 5 GROUND MONITORINGTER ❑6 ANNUALTESTING 7 CONTINUOUS INTERSTITIAL ❑ 8 SIR ❑ 9 WEEKLY MANUAL ❑10 MONTHLYTESTING TANK [—] 95 UNKNOWN ❑ 99 OTHER MONITORING 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? THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,ANLZTO.THE BE$!T OFYY KNOWLEDGE,IS TRUE AND CORRECT ATE TANK OWNER'S NAME (PRINTED d SIGNATURE) / r LJ r J f01 I- i. it Al LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY# - TA�J�—I STATE 01 m PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPL�N-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. MUST BE COMPLETED FOR INSTALLATIONS.THIS FORM SHOULD BE ACCOMPANIED BY A PLOT P ILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THEWGROUND STORAGE TANK REGULATIONS FIIRAI R IC.ASI