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- �yyou•crs ` STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD 3 r UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B .i - C�LIt4rt H,r. COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT 3 RENEWAL PERMITS CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ONSITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE ❑ 6 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: A44c& I. TANK DESCRIPTION COMPLETE ALL ITEMS-- SPECIFY IF UNKNOWN A OWNER'S TANK I.D.N q— S. MANUFACTURED BY: C. DATE INSTALLED(MOIDAYNEAR) / /--1 0 D. TANK CAPACITY IN GALLONS: II.TANK CONTENTS IF A-1 IS MA KED,c MPLETE ITEM C. A. 1 MOTOR VEHICLE FUEL LJ 4 OIL B. C ❑ 1. REGULAR UNLEADED 3 DIESEL ❑ 6 AVIATION GAS LCL 1 PRODUCT ❑ 1b PREMIUM UNLEADED ❑ 4 GASAHdL ❑ 7 METHANOL 2 PETROLEUM BO EMPTY �`� ❑ 1c MIDGRADE UNLEADED ❑ 5 JET FUEL ❑ B M85 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN 2 WAST CEADEo-, O 99 OTHER(DESCRIBE IN ITEM D.BELCH D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED / C.A.S.4: Ill. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A, ,AND C,AND ALL THAT APPLIES IN BOX D AND E A. TYPE OF 1 DOUBLE WALL D 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 E::] 2 STAINLESS STEEL ❑ 3 FIBERGLASS x 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL 175 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER C.INTERIOR 1 RUBBER LINED D 2 ALKYD LINING 3 EPDXY LIN4NG 4 PHENOLIC LINING LINING OR ❑ 5 GLASS LINING ;<6 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 100`,6 METHANOL? YES NO Is D.EXTERIOR ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC CORROSION PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE ❑95 UNKNOWN ❑ 99 OTHER IF E. SPILL AND OVERFILL,etc. SPILL CONTAINMENT STALLED(YEAR) OVERFILL PREVENT) N UIPMENT INSTALLED(YEAR) 1� DROP TUBE YES NO STRIKER PLATE YES NO DISPENSER CONTAINMEN 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 2 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 i BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)AID 4 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL WI COATING A U 8 100% METHANOL COMPATIBLE WIFRP PROTECTION A U 9 GALVANIZED STEEL/A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION 1 MECHANICAL LINE LEAK 2 LINE TIGHTNESS ❑3 COnNUOUS INTERSTITIAL �A ELECTRONIC LINE E 5 AUTOMATIC PUMP O 99 OTHER DETECTOfl TESTCNG MOMTORING LEAK DETECTOR SHUTDOWN V,TANK LEAK DETECTION 1 VISUAL CHECK ❑ 2 MANUAL RECONCILIATION INVENTORY E] 3 MO I ORING ❑ 4 AUTOMATGAUGING IC TANK ❑ 5 GROUND MONITORING TER ❑ B TETANK STING 7 MONITOR CONTINUOUS INTERSTITIAL ❑ 6 SIR ❑ 9 gENKLY MANUAL ❑10 TESTING Y TANK ❑ 95 UNKNOWN 17199 OTHER VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) 1.ESTIM T D DATE LAST USED(MOIDAYNR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH SUBSTANCE REMAINING GALLONS INERT MATERIAL? YES [:] NQ ❑ 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 1(P RINTED d SIGNATURE) LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY# 00 TANK# STATE I.D.# PERMIT NUMBER PERMIT APPROVED BYIDATE PERMIT EXPIRATION DATE THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORM A HAS BEEN PILED, FORM C MUST BE COMPLETED FOR INSTALLATIONS. T IS F RMI�l SHOULD BE ACCOMPANIED BY A PLOT Pf FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THF fERGRO�D STORAGE K REGULATIONS { I FORM B (fi-95)