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• STATE OF CALIFORNIA • �Aa°"'cea STATE WATER RESOURCES CONTROL BOARD >y g UNDERGROUND STORAGE TANK PERMIT APPLICATION -FORM B = COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ❑ i NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ONSITE ONE REM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ B TANK REMOVED O DBA OR FACILITY NAME WHERE TANK IS INSTALLED: I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A OWNER'S TANK I.D.Y B. MANUFACTURED BY: C. DATE INSTALLED(MOIDAV/YEAR) 9/ D. TANK CAPACITY IN GALLONS: JV7 UUd II.TANK CONTENTS IF A-1 IS MARKED,COMPLETE ITEM C. A- \ 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C. E77kREGULARUNSOED ❑ 3 DIESEL ❑ 6 AVIATION GAS ❑ 2 PETROLEUM ❑ 80 EMPTY 1 PRODUCT ❑ 1b PREMIUM UNLEADED ❑ 4 GASAHOL ❑ 7 METHANOL ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ Ic MIDGRADE UNLEADED ❑ 5 JET FUEL [_] 8 M85 ❑ 2 LEADED ❑ 99 OTHER(DESCRIBE IN TEND.BELOW) D. IF(A1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S.N: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.8,AND C,NO 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 ESL SINGLE WALL ❑ 4 SINGLE WALL IN A VAULT ❑ 99 OTHER B. TANK ❑ 1 BARE STEEL ❑ 2 STAINLESS STEEL [:7\3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP (PHIRBTy 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 ITN 10096 METHANOL? YES_ NO— ppppp��......,..,,,, D.EXTERIOR ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING E] 3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC CORROSION PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE 09 UNKNOWN ❑ 99 OTHER E.SPILL AND OVERFILL,aL0. SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) DROP TUBE YES_ 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 AQrl PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER S. CONSTRUCTION ACV 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)ACU 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 ❑ 11W ❑ OEIECfOIFAI! El NE TIGMN£53 1 MECNINI2 U3 CWINS wiER51111RL 4 ELECn1014C UNE 5 AUTOWnC PURCAL LINE M nNG MO MNG ❑ LEMI OEIECOR ❑ MP 91U1GOWN ❑ 99 OTHER V.TANK LEAK DETECTION y� ❑ 1 VISUAL CHECK U 2 ANNUAL RECONCILMANUAL IATIONORY ❑ 3 VAOZEMONIITORING ❑ 4 GAUGING AUTOMATIC TANK ❑5 MON TORINGGROUND WATER 6 TESTINGTANK ❑ 7 MONITORING INTERSTITIAL ❑ 8 SIP ❑ 9 TANK GAUGINGAL ❑ 10 MESTINGV TANK E] 95 UNKNOWN 99 OTHER VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) 1.ESTIMATED DATE LAST USED M �Yn 9� 2. SUBSTANCE REESTIMATED MA TY NI GF GALLONS 3 WASNERT MATERITANK FILLEDAL?H VES ❑ 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 (PRINTED 6 SIGNATURE) -7 ATE LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNN# JURISDICTION# FACILITY# TANK# STATE I.D:# m / D S -711D /c�gG PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE Ll THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORMA HAS BEEN FILED. FORM C MUST BE COMPLETED FOR INSfALLATIOAS. THIS FORM FORM B (695) SHOULD BE ACCOMPANIED BY A PLOT PLO LE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE v GROUND STORAGE TANK REGULATIONS FOR007/68i