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STATE OFCAUFORNIA STATE WATER RESOURCES CONTROL BOARD "� G o UNDERGROUND STORAGE TANK PERMIT APPLICATION-FORM B e� - COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. ❑ 7 PERMANENTLY CLOSED ON SIT O 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION g TANK REMOVED ❑ 2 IN MARK ONLY 0 I NEW PERMIT O g TEMPORARY TANK CLOSURE TERIM PERMIT 4 AMENDED PERMIT ONE ITEM TT DBA OR FACILITY NAME WHERE TANK IS INSTALLED: W V I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN B. MANUFACTURED By: A OWNERS TANK I.D.# D. TANK CAPACITY IN GALLONS: C. DATE INSTALLED(MOIDAWIEAR) II.TANK CONTENTS IF A.1 IS MARKED,COMPLETE ITEM C. #REGULAR UNLEADED ❑ 3 DIESEL ❑ 5 AVIATION GAS :3 lb PREMIUM UNLEADED ❑ 4 GASAHOL ❑ T METHANOL ❑ 1 MOTOR VEHICLE FUEL �4 OIL B. C. T` O 80 ff. ❑ 1 PRODUCT El ❑ 2 PETROLEUM tc MIOGRAOE UM.EADED 5 JET FUEL B MBS ❑ EMICAL E] PRODUCT ❑ 95 UNKNOWN 2 WASTE 2 LEADED 99 OTHER(DESCRIBE EN IT DAD.BELOM 3 CH D. IF(At)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED III. TANK CON UCTION MARK ONE ITEM ONLY IN BOXES A B,AND C,AND ALL THAT APP IES IN BOX D AND E A. TYPE OF 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR R ❑ 5 INTERNAL BLADDER SYSTEM E395 UNKNOWN SYSTEM ❑ 2 GLE WALL ❑ 4 SINGLE WALL IN A VAULT ❑ 99OTHER B. TANK ❑ I BARE S L ❑ 2 STAINLESS STEEL 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 5 POLYVINYL CHLORID ❑ 7 ALUMINUM ❑ B 100% METHANOL COMPATIBLE W/FRP (PAm#ry Tok) a 9 BRONZE ❑ 10 GALVANIZED ST L ❑ 95 UNKNOWN ❑ 99 OTHER C.INTERIOR ❑ 1 RUBBER LINED 2 ALKYD LININ ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING LINING OR ❑ 5 GLASS LINING 5 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WI 100% ANOL7 YES_ NO— D.EXTERIOR ❑ 1 POLYETHYLENE WRAP [D 2 NG F-13 VINYL WRAP E] 4 FIBERGLASS REINFORCED PLASTIC CORROSION PROTECTION El CATHODIC PROTECTION ED91 O ❑95 UNKNOWN ❑ 99 OTHER E.SPILL AND OVERFILL,BM. SPILL CONTAINMENT INST D(YEAR)X OVERFILL PREVENTION EQUIPMENT INSTALLED IYEAR) DROPTUBE VES_ RIKERPLATE VES_ NO_ DISPENSER CONTAINMENT VES_ NO IV.PIPING INFORMATION CIRCLE A IF LIVE GROUND OR U NDERGROUNO,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 SINGLEWAL A U 2 DOUBLE WALL A 3 UNED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND A U 1 BARE STF, A U 2 STAINLESS STEEL A U 3 INYL CHLORIDE(PVC)A U 4 FIBERGLASS PIPE CORROSION A U 5 ALUMI M A U a CONCRETE A U 7 STEEL ATING A U g 100% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GAL IZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKN A U 99 OTHER D. LEAK DETECTION ❑1 ImE LEAK ❑2 W# TMH9t=55 ❑3 mx9E0003 INreRe9nu ❑4 BECIBDNIC UN Aurowlw ww DEiE OR TEnW MOMipRWG LEM DEtECT09 ❑ 99 OTHER V.TANK LEAK DETECTIO ❑ 1 VISUAL CHECK ❑ 2 RECO CI A IONORY ❑ 3 M�ORING ED4 GAUGINGAUTOMATIC TANK ❑ 5 MONITORING GROUND TER F-18 TE�NGTANK ❑ 7 MON TOR NG INTERSTITIAL ❑ B SIR ❑ 9 ME,GA=AL ❑10 MONTTNG HLY TANK ❑ 95 UNKNOWN ❑99 OTHER TES VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) L 1.ESTI TED DATE UST US M MR) 2,ESTIMATED OUANTITY OF 3.WAS TANK FILLED WITH YES NO I J(I .- --- SUBSTANCE REMAINING GALLONS INERT MATERIAL 7 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&SIGNATURE) LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW STATE I.D:# COUNTY# JURISDICTION# FACILITY# TANK# = — PERMIT NUMBER PERMIT APPROVED BY/DATE 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 PLA" FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE W'ERGROUND STORAGE TANK REGULATIONS FORM (695) ` q- / l / ('. � 4/e