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w .o' STATE OFCAUFORNIAa STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION -FORM B COMPLETE A SEPARATE FORM FOR H TANK SYSTEM. MARK ONLY ❑ I NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION a T P NTLY OSED ONE ITEM ❑ 2 INTERIM PERMIT ❑ a AMENDED PERMIT Q 8 TEMPORARY TANK CLOSURE ❑ e T E,10V DBA OR FACILITY NAME WHERE TANK IS INSTALLED: r I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A OWNERS TANK 1.D.t B. MANUFACTURED BY: C. DATE INSTALLED(MCIDAYNEAR) 0. TANK CAPACITY IN GALLONS: II.TANK CeNTENTS IF A-1 IS MARKED,COMPLETE ITEM C. A 1 MOTOR VEHICLE FUEL Q d OIL 8. C. to FIEGUI UNLEADED J DIESEL ❑ 6 AVIATION GAS ❑ 2 PETROLEUM ❑ 80 EMPTY FRODUOT t0 PREMIJM UNLEADED a GASAHOL T METHANOL ❑ ❑ 95 UNKNOWN 2 WASTE le MOGRADE UNLEADED 5 JETFUEL 8 M85 3 CHEMICAL PRODUCT ❑ ❑ 9H OTHER(DESCRBE IN REMO.BELOW) D. IF(A1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED 2 LEADED C.A.S.Y. 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 ❑ a SINGLE WALL IN A VAULT ❑ 99 OTHER B. TANK ❑ I BME STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS O d STEEL CLAD W/FIBERGLASS REINFORCED PuSTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYWNYL CHLORIDE ❑ T ALUMINUM ❑ 8 100% METHANOL COMPATIBLE WIFRP (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER C.INTERIOR ❑ I RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 6 PHENOLIC LINING LINING OR ❑ S Guns UMMS ❑ 6 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO— D.EXTERIOR I POLYETHYLENE WRAP 2 COATING CORROSION ❑O 3 Wim- WRAP ❑ a FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODICPROTECOO ❑ 91 NONE a 95 UNKNOWN ❑ 99 OTHER E SPILL AND OVERFILL.et1:. SPILL CONTAINMEM INSTALLED(YEAR) OVERFILL PREVENTION EOULPMENT INSTALLEp(YEAR) DROP TUBE YES_ NO_ STRIKER PLATE YES_ NO_ DISPENSER CONTAINMENT YES_ NO IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND,BOTH IF APPLICABLE FSYSTEMTYPE A U I SUCTION A U 2 PRESSURE A U 3 GRAVITY A U A FLEXIBLE PIPING A U 99 OTHER N A U 1 SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U B9 OTHER A U 1 BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A U a FIBERGLASS PIPE A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL W/COATING A U 6 100% METHANOL COMPATISLEWIFRP - A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER 0. LEAK DETECTION ❑t 'Ea'u°T'u ANB LFAIc ❑2 uE I%;Hma5 ❑3 aKlaAlas NRnrm1.L ❑a as-moNc O 5 > Rnv Q yy oTNeq [EtEtTOR 1EST61O V.TANK LEAK DETECTION ❑ 1 VISUAL CHELK ❑ 2 RECONCILIATIONUAL O� ❑ J VADOZE MONITORING ❑ a GAUGINGAUTOMATIC TANK ❑ 5 MONITORING TER ❑ 6 TANNUAL ESTTNGTANK ❑ 7 MpNITII'ORONUGS INTER57TT1AL ❑ 8 51R ❑ 9 TANK WEEKLY NGAL❑ 10 MONTHLY TANK Q 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION(P£RMaN£NT CLOSURE N.PLAM STING 1.ESTIMATED DATE LAST USED(MOIDAWYR) I 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES ❑ NO❑ SUBSTANCE REMAINING GALLONS INERT MATERIAL 7 THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY.AND 7.0 THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT TANK OWNERS NAME (PRIRm A9 HATURE) DATE LOCAL AGENCY USE ONLY THE STATE L).NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW , ! —2 C�TOUNTY X JURISDICTION a FACILITY a TANK A / STATE 04 STATE / I z O Z O v PERMIT NUMBER PERMIT APPROVED SYMATE J PERMIT EXPIRATION DATE I a � THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPUCATID" FORM A.UNLESS A CURRENT FORMA HAS BEEN FILED. FORM C....ST BE COMPLETED FOR INSTALLATIONS.ITS FISHOULD BE ACCOMPANIED BY A PLOT PI" -HIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE I"— LUNO STORAGE TANK flEGUUTKINS FORM B (III - _� T �� FOIIID1asm