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V STATE OFCAUFORNIA 1-/ STATE WATER RESOURCES CONTROL BOARD i`�•c' •.'c�+ UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. In o MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT CP�5 CHANGE OF INFORMATION ❑ 7 PE OSED ON ONE REM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ e O D. DBA OR FACILITY NAME WHERE TANK IS INSTALLED: t I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A OWNER'S TANK 1.0.N l� B. MANUFACTURED BY: C. DATE INSTALLED(MO/DAY/YEAR) J D. TANK CAPACITY IN GALLONS: If.TANK CONTENTS IF A-1 IS MARKED.COMPLETE ITEM C. A 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C, 1a REGULAR UNLEADED n`�j 3 DIESEL ❑ 6 AVIATION GAS ❑ 2 PETROLEUM ❑ W EMPTY 1 PRODUCT 1D PREMIUM UNLEADED u 4 GASAHOL ❑ 7 METHANOL ❑ 3 CHEMICALPRODUCT ❑ 9S UNKNOWN ❑ 2 WASTE ❑ 1e MIDGRADE UNLEADED 5 JET FUEL ❑ 8 M85 ❑ 2 LEADED 99 OTHER(DESCRIBE N ITEM D.BELOW) D. IF A.1)IS NOT MARKED. ENTER NAME OF SUBSTANCE STORED C.A S.0: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A B,AND C.AND ALL THAT APPLIES IN BOX D AND E A. TYPE OF ❑ 1 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 S. TANK ❑ 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 F18ERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ B 100% METHANOL COMPATIBLE W/FRP (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER C.INTERIOR ❑ 1 RUBBER UNED ❑ 2 ALKYD LINING ❑ 3 EPDXY UNING ❑ 4 PHENOLIC LINING LINING OR ❑ 5 GLASS LINING ❑ 6 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO— D.EXTERIOR ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC CORROSION PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER E SPILL AND OVERFILL,aLC. SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) DROP TUBE VES_ NO_ STRIKER PLATE YES_ NO_ DISPENSER CONTAINMENT YES_ NO IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U I SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER S. CONSTRUCTION A U 1 SINGLE WALL A U 2 DOUBLE WALL A U 3 UNED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND A U I BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A U 4 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 ❑1 Mlaw UMI Ue ❑2 UTE tgmx¢ss ❑3 wanaTwus WrERsnnAl 4[LEcmoNc uaE s AumMATk ww OflFGfOR TESIMG T DRWI ❑ TEAR lIE1EC10R 1:19MLUWN E:) 99 OTHER V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 MONITORING EUALINVENTORY ❑ 3 ZE ❑ 4 AUTOMATIC TANK ❑ 5 GROUNDTER ❑ 6 ANNUAL TANK E] 7INTERSTITIAL ❑ qLIAlION VATORING AUCNGTESTING 8 SIR ❑ 9 WEEKLY MANUAL ❑ 10 MONTHLY TANK ❑ 95 UNKNOWN ❑ 99 OTHER TANK GA GING TESTING VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN.PLACE) I.ESTIMATED DATE LAST USED(MO/DAY/YR) 2 ESTIMATED OUANTTTY OF 3.WAS TANK FILLED WITH YES ❑ NO❑ 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 (PRINTED 8 SIONATURE) LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW d COUNTY N JURISDICTION k FACILITY k TANK N STATE I.D:# ml PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE I ! THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. FORM C MUST BE COMPLETED FOR INSTALLATIONS THIS FORM SHOULD BE ACCOMPANIED BY A PLOT PI '.E THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE I- GROUND STORAGE TANK REGULATIOT{; I b FORM 8 (696) `I ' /,S 1