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STATE OF CALIFORNIA ` '�� `.. STATE WATER RESOURCES CONTROL BOARD p UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B =° 1 COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ ? PERMANENTLY CLOSED ONSITE ONE REM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ B TANK REMOVED I� DBA OR FACILITY NAME WHERE TANK IS INSTALLED: I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A OWNER'S TANK I.D.# B. MANUFACTURED BY: C. DATE INSTALLED(MO/DAY/YEAR) D. TANK CAPACITY IN GALLONS: II.TANK CONTENTS IFA-1 IS MARKED,COMPLETE ITEM C. A ❑ 1 MOTOR VEHICLE FUEL 4 OIL g, C TA 18 REOUR UNLEADED 3 DIESEL 6 AVIATION GAS F-12 PETROLEUM "'''-----❑-- ___80 EMPTY ❑ 1 PRODUCT ❑ 1E PREMIUM UNLEADED 0 E]4 GASAHOL ❑ T METHANOL ❑ 3 CHEMICAL PRODUCT ❑ 85 UNKNOWN 2 WASTE ❑ 1c MIDGRADE UNLEADED E] 5 JETFUEL E] B M85 ❑ 2 LEADED ❑ 99 OTHER IDFSCRIBE IN REM D.BELOW) D. IF(A1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A S.0: 495 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 ❑ I DOUBLE WALL ❑ 3 SINGLE WALL WTH EXTERIOR UNER ❑ 5 INTERNAL BLADDER SYSTEM ❑ 95 UNKNOWN SYSTEM 2 SINGLE WALL ❑ 4 SINGLE WALL IN A VAULT ❑ 99 OTHER B. TANK 1 BARE STEEL O2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ ? ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP (P"MWY TBRIV ❑ 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 �E<8 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NOL/ D.EXTERIOR ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC CORROSION PROTECTION ❑ 5 CATHODIC PROTECTION 91 NONE 09 UNKNOWN ❑ 99 OTHER E.SPILL AND OVERFILL,etc. SPILL CONTAINMENT INBTANo R) OVERFILL PREVENT NEOUIPMENT INSTALLED(YEAH) DROP TUBE YES_ NO STRIK RPLATE YES NO DISPENSER CONTAINMENT YES_ NO� IV.PIPING INFORMATION CIRCLE A IFABOVEGROUNDOR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE AQleh GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION A 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 V BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYWNYL CHLORIDE(PVC)A U 4 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U T STEEL W/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 DETECTIONC NW U InCN M ME OF NE TwM M wwN4lau WIERNImAL 4 ELECiROMC NE uro#An ❑I oElEcroA ❑2 UTEsnxB ❑3 9oMTaIPw ❑ uuc 9ETEcrrn ❑SAW s8uT0ovm 99 oTHEA V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 RECONCILIATIONNUAL INVENTORY ❑ 3 MONIITORING OZE ❑ 4 AUTOMATIC TANK ❑ 5 GROUND MONITORING TER�❑1 6 ANNUALTESTING ❑ ? MONITORING us INTERSTITIAL ❑ 8 SIR ❑ 9 TANK GAUGING ❑10 TIESTINGY TANK ❑ 95 UNKNOWN 99 OTHER VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE B4-PLACE) 1.EST TED DATE LAS U D(MO/DAV/YR) 2.ESTIMATED OUANTTY OF 3.WAS TANK FILLED WITH SUBSTANCE REMAINING O 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 DATE (PRINTED 6 SIGNAIURD LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION k FACILITY# TANK# Q STATE I.Dl s- O 31 zDl 15-1 -ol e,1-31lZ2J PERMIT NUMBER PERMIT APPROVED BYIDATE PERMIT EXPIRATION DATE THIS FORM MUST BE ACCOMPANIED BY PERMIT APP)--fW-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. FOP"C MUST BE COMPLETED FOR INSTALLATIONS.THIS FORM SHOULD BE ACCOMPANIED BY A PLO- ILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING T FORM B (6.95) GROUND STORAGE TANK REGULATIONS ~��