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- STATE OF CALIFORNIA +� STATE WATER RESOURCES CONTROL BOARD y+dam tl 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 ❑ 7 PERMANENTLY CLOSED ON SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ✓ 8 TANK REMOVED D DBA OR FACILITY NAME WHERE TANK IS INSTALLED: O� I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A OWNER'S TANK 1.0.# 77 B. MANUFACTURED BY: C. DATE INSTALLED(MC/DAYIYEAR) D. TANK CAPACITY IN GALLONS: II.TANK CONTENTS IF A-1 IS MARKED,COMPLETE ITEM C. MOTOR VEHICLE FUEL 4 OIL B. C. a REGULAR UNLEADED ❑ 3 DIESEL ❑ 6 AWATIONGAS ❑ ❑ tb PREMIUM UNLEADED ❑ 4 GASAHOL ❑ 7 METHANOL A ❑ 2 PETROLEUM ❑ 80 EMPTY Y\L I PRODUCT ❑ 1C MNGRADE UNLEADED 5 JET FUEL ED8 M65 ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN !—❑-2 WASTE ❑ 2 LEADED g 99 OTHER(DESCRIBE IN REM D.BELOWI D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A S.#: III, TANK CONSTRUCTIO MARK ONE ITEM ONLY IN BOXES A,B,AND C,AND ALLTHAT APPLIES IN BOX D AND E A. TYPE OF ❑ 1 DOUBLE ALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 5 1 NAL BLADDER SYSTEM ❑ 95 UNKNOWN SYSTEM ❑ 2 SINGLE W ❑ 4 SINGLE WALL IN A VAULT 9 OTHER B. TANK ❑ i SASE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINU ❑ 8 100% METHANOL COMPATIBLE W/FRP WNm81YT-K) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UN N ❑ 99 OTHER C.INTERIOR ❑ i RUBBER LINED 2 ALKYD LINING ❑ 3 OXY LINING ❑ d PHENOLIC LINING LINING OR ❑ 5 GLASS LINING 6 UNLINED ❑ UNKNOWN ❑ 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WI 100% METHANOL? B_ NO_ D.EXTERIOR ❑ i POLYETHYLENE WRAP ❑ 2 DATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC CORROSION ❑ ❑ PROTECTION ❑ 5 CATHODIC PROTECTION ❑ gt NE 95 UNKNOWN 99 OTHER SPILL CONTAINMENT INSTALLED(Y ) OVERRLL PREVENTION EQUIPMENT INSTALLED(YEAR) E.SPILL AND OVERFILL,#I0. DROP TUBE YES_ NO_ IKER PLATE YES_ NO DISPENSER CONTAINMENT YES_ NO IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND R U IF UNDERGROUND.BOTH IF APPUCA13LE A. SYSTEM TYPE A U 1 SUCTION AU 2 ESS E A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL A U DOUBLE ALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND A U / BARE STEEL A 2 STAINLESS EL A U 3 POLYVINYL CHLORIDE(PVC)A U d FIBERGLASS PIPE CORROSION A U 5 ALUMINUM U 6 CONCRETE A U 7 STEEL W/COATING A U B 100% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STIES A U 10 CATHODIC PRO CTION A U 95 UNKNOWN A U 99 OTHER - D. YECNAVICAL UNE UUJ( 2 UNE lI6MNE5E 3 CONIINU INIER9TIigl 4 EIECDWMC UNE 5 AIROMATC PIMP 99 OTHEfl D. LEAK DETECTION ❑ o CWI UNE ❑ Monk ❑ U oE1EC1CR ❑ sNlnoovm ❑ V.TANK LEAK DETECTION ❑ / VISUAL CHECK RECONCILIATION CILIATIONORY ❑ 3 MOWNIITORIN ❑ 4 GAUGINAUTOMAG MONITORING TANK ❑5 MON TORINGGROUND TER ❑6 TESTINANNUAL G ❑ 7 MON TOUS R NG INTERSTITIAL g SIR ❑ 9 TANK GAUGIN AL ❑ 10 MONTHLY TANK ❑ 95 UNKNOWN ❑99 OTHER VI.TANK CLOSURE INFOR TION(PERMANENT CLOSURE IN-PLACE) 1.ESTIMA D DATE USED YNR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES ❑ C SUBSTANCE REMAINING 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 (PRINTF 99WATURE) LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW CrT[qO��UNTY# JURISDICTION# FACILITY# Q- TANK# STATE I.Dl PERMIT NUMBER PER MIT 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 PI'-' FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE....'ERGROUND STORAGE TANK REGULATIONS FORM (605)