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e4oNcee n p STATE OF CALIFORNIA STATEWATER RESOURCES CONTROIBDARD #B UNDERGROUND STORAGE TANK PERMIT APPLICATION FORM B :r _ COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. ❑ 7 PERMANENTLY CLOSED ON SITE MARK ONLY 1:3 i NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ONE ITEM ❑ 2 INTERIM PERMIT O 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE 6 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: 5 . 1. TANK DESCRIPTION COMPLETE ALL ITEMS– SPECIFY IF UNKNOWN 8. MANUFACTURED BY: A OWNER'S TANK I.D. C. DATE INSTALLED(MO/DAYNEAR) D. TANK CAPACITY IN GALLONS: Ia 11.TANK CONTENTS IF A-1 IS MARKED,COMPLETE ITEM C. 1 MOTOR VEHICLE FUEL ❑ d OIL g, C. to REGULAR UNLEADED 3 DIESEL ❑ 6 AVIATION GAS O` 1b PREMIUM UNLEADED 4 GASAHOL ❑ 7 METHANOL ❑ 2 PETROLEUM ❑ BO EMPTY 1 PRODUCT ❑ 1c MIDGIME UNLEADED O 5 JET FUEL ❑ 6 Mg5 ❑ 3 CHEMICALPRODUCT ❑ 95 UNKNOWN _ ❑ 2 WASTE ❑ 2 LEADED ❑ 99 OTHER(DESCRIBE N REM O.BELOW) O. IF(A1)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 AP ES IN BOX D AND E A. TYPE OF ❑ I LE WALL ❑ 3 SINGLE WALL WITH EXTERIOR ER ❑ 5 INTERNAL BLADDER SYSTEM ❑ 95 UNKNOWN SYSTEM ❑ 2 SING ALL ❑ 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 ❑ 8 POLWINVL CHLO E ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED EL ❑ 95 UNKNOWN ❑ 99 OTHER C.INTERIOR ❑ I RUBBER LINED NS� 2 ALKYD ING ❑ 3 EPDXY LINING ❑ 4 PHENOUC LINING LINING OR ❑ 5 GLASS LINING 6 UN D ❑ 95 UNKNOWN ❑ 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH METHANOL? YES— NO— D.EXTERIOR ❑ 1 POLYETHYLENE WRAP COA G ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC CORROSION PROTECTION ❑ 5 CATHODIC PROTECTION 091 NONE E)95 UNKNOWN E:] 99 OTHER E.SPILL AND OVERFILL,Mc. SPILL CONTAINMENT STALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) DROP TUBE YES NO Sl AW4RPLATE YES_ NO_ DISPENSER CONTAINMENT YES NO IV. PIPING INFORMATION CIRC A IF ABOVE GROUND OR U IF UN GROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTIO A U 2 PRESSURE 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION A U i SI WALL A U 2DOUBLE WALL A U UNED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND A U 1E STEEL A U 2 STAINLESS STEEL A U 3 LYVINYL CHLORIDE(PVC)A U 4 FIBERGLASS PIPE CORROSION A U S ALUMINUM A U a CONCRETE A U 7 S W/COATING A U 6 100% METHANOL COMPATIBLE W/FRP PROTECTION A U GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U UNKNOWN A U 99 OTHER D. LEAK DETECTION I ME--LINE LEAN 2 M TISK M 3 wNnMlcua OEIEcfGR ❑ NrS a [:]4 !C LINE 5 9Tjc WW TES9AMMTWIW xmq n ❑ 99 —En V.TANK LEAK DEPiCTION ❑ 1 VISUAL CHECK ❑ 2 RECONCI INVENTORY ❑LIATION 3 M�ORING ❑ 4 GAUGING MONITORING TANK ❑5 GROUND WATER ❑6 ANNUNGTANK ❑ 7 CONTINUOUS MONITORING INTERSTITIAL [:1 B SIR ❑ 9 WE K1GAUIGING� ❑10 TESTING TANK ❑ 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) 1.EST DDAUSED nR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES ❑ NO SUB STANCEREMAINING GALLONS INERT MATERIAL 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 a SIGNATURE) LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW STATE I.D:# COUNTY# JURISDICTION# FACILITY QTANK# 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 INSTALLATIONS.THIS FORM SHOULD BE ACCOMPANIED BY A PLOT PLO" FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE PI FRGROUND STORAGE TANK REGULATIONS FORM B (6-95) `� QW- X-44-4