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• • STATE OFCALIFORNIA • "`so��.�'o STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B m COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ONSITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED I J DBA OR FACILITY NAME WHERE TANK IS INSTALLED: I. TANK DESCRIPTION COMPLETE ALL ITEMS— SPECIFY IF UNKNOWN / A. OWNER'S TANK I.D.p B. MANUFACTURED BY: I C. DATE INSTALLED(MO/DAY/YEAR) D. TANK CAPACITY IN GALLONS: II.TANK CONTENTS IFA-1 IS MARKED.COMPLETE ITEM C. A 0s 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C 1a REGULAR UNLEADED ❑ 3 DIESEL ❑ 6 AVIATION GAS / �1E PREMIUM UNLEADED ❑ 4 GASAHOL ❑ 7 METHANOL ❑ 2 PETROLEUM E::] 80 EMPTY I PRODUCT ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE 2 LEADEMIDGRAD UNLEADED ❑ 5 JET FUEL ❑ B EM0 ❑ 2 LEADED ❑ 99 OTHER(DESCRIBE IN REM 0.BELOYO D. IF(p1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S.#: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A B AND C,AND ALL THAT APPLIES IN BOX D AND A. TYPE OF IS1 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 I 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 W/FRP (Primary 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 _,8 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH IDD% METHANOL? YES_ NO— �5 D.EXTERIOR F__] 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP I S 4 FIBERGLASS REINFORCED PLASTIC CORROSION Y-" PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE ❑95 UNKNOWN ❑ 99 OTHER E.SPILL AND OVERFILL,BTC. SPILL CONTAINME T INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) DROPTUBE YES NO STRIKER PLATE YES NO DISPENSER CONTAINMENT VES NO IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION A 2 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL A U 2DOUBLE WALL A C)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 64 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 tq1 AffCK4 LUNE UM 2 UNE VGMNES$ 3 OGMINIIWS IMERSTIIIAL 4 EUXTIMIC UNE 5 AMOIMTIC PUMP OETECTOP TESTING MIX#TORING ❑ UT K DETECTOR ❑ SHUTDOWN ❑ 99 OTHER V.TANK LEAK DETECTION ❑ GROUND I NTERSTITIAL RING8 VISUAL CHECK ❑ RECONCILI TIONORV ❑ 3 MONIITORING 4 GAUGNGIC TANK ❑5 MONTORINGTER ❑ 8 TESTINGTANK SIR ❑ 9 TANKLY MANUAL ❑ 10 MONTHLY TANK ❑ 95 UNKNOWN ❑ 99 OTHER TING VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PUCE) 1.ESTIMATED DATE LAST USED(MO/DAYNR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES ❑ NO❑ SUBSTANCE REMAINING GALLONS INERTMATERIAL? THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT TANK OWNERS NAME DATE (PRINTED B SIGNATURE) /( _� XY f /`r LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY# TANK#D D(o STATE 04 m lv I 7110 (o PERMIT NUMBER PERMIT APPROVED BYIDATE PERMIT EXPIRATION DATE THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORMA HAS BEEN FILED. FORM C MUST BE COMPLETED FOR IN LLATIONS.THIS FORM FORM B (6-95) SHOULD BE ACCOMPANIED BY A PLOT PL jfLE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE 0GROUND STORAGE TANK REGULATIONS FOR0D7/&R7