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STATE OF CALIFORNIA c °a STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B .,.oma ,A` COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ONE ITEM ❑ 2 INTERIM PERMIT 4 AMENDED PERMIT ❑ b TEMPORARY TANK CLOSURE ❑ 6 TANK REMOVED CLOSED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: -_3 3 I. TANK DESCRIPTION COMPLETE ALL ITEMS SPECIFY IF UNKNOWN A. OWNER'S TANK I.D.N B. MANUFACTURED BY! �/ C. DATE INSTALLED(MOIDAYNEAR) D. TANK CAPACITY IN GALLONS: l� II.TANK CONTENTS IF A-1 IS MARKED,COMPLETE ITEM C. A- )<�, MOTOR VEHICLE FUEL [:]'4 OIL B. rte'/. C ❑ to REGULAR UNLEADED 3 DIESEL ❑ 6 AVIATIONGAS F72 PETROLEUM ❑ BO EMPTY T PRODUCT ❑ 1b PREMIUM UNLEADED ❑ 4 GASAHOL ❑ 7 METHANOL ID 1c MIDGRADE UNLEADED ❑ 5 JET FUEL ❑ 6 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,S.AND C,AND ALL THAT APPLIES IN BOX D AND E A. TYPE OF 1 DOUBLE WALL 7] 3 SINGLE WALL WITH EXTERIOR LINER ❑ 5 INTERNAL BLADDER SYSTEM ❑ 95 UNKNOWN SYSTEM ❑ 2 SNGLE 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 ❑ 6 POLYVINYL CHLORIDE: ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE WIFRP (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL a 95 UNKNOWN ❑ 99 OTHER C.INTERIOR ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING 3 EPDXY LINNG ❑ 4 PHENOLIC LINING LINING OR ❑ 5 GLASS LINING 6 UNLINEDa ,9�5rFUNKNOWN F-199 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL7 YES¢ NO D.EXTERIOR ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC CORROSION PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE 95 UNKNOWN 04 ❑ 99 OTHER E.SPILL AND OVERFILL,etc, SPILL CONTAINMEN I STALLED(YEAR) OVERFILL PREVENTION EOUIPMENT 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 A 0 2 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL A@ 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 WICOATING A U B 100% METHANOL COMPATIBLE WIFRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER 1 MECHANICAL LINE LEAK [::]2 LINE TIGHTNESS 3 CONTINUDUS INTERSTITIAL 4 ELECTRCNIC UNE 5 AUTOMATIC PUMP 99 OTHER D. LEAK DETECTION DETECTOR TESTING ❑ MONITCRING LEAK DETECTOR SHUTDOWN ❑ V.TANK LEAK DETECTION F-1 1 VISUAL CHECK ❑ 2 RECONCILIATIONMANUAL MONITORING ❑ 3 VADOZE MONIITORING ❑ 4 AUTOMATGAUGINGIC TANK ❑ 5 GROUND MONITORING TER 7] 5 TESTINGTANK 7 CON TORININUOU INTERSTITIAL ❑ 8 SIR ❑ 9 TWEKLY ANRGA MANUUAL ❑ 10 MONTHLY TANK ❑ 95 UNKNOWN Ll 99 OTHER VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) 1.ESTIMATEqA? ST USED(MO/DAY/YR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES ❑ NO❑ ! SUBSTANCE REMAINING GALLONS INERT MATERIAL? T! IS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT TANK OWNER'S NAME DATE (PRIN7ED 6 SIGNATURE) LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY# a TANK# STATE LD.# PERMIT NUMBER PERMIT APPROVED BYICATE 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. HIS R SHOULD BE ACCOMPANIED BY A PLOT PILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE WGROUND STORAGE TANK REGULATIONS FORM B I6-95)