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• 0 o. e, STATE OF CALIFORNIA `^^`� ,�* STATE WATER RESOURCES CONTROL BOARD D UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B ""� COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. �"�^�""�^ o MARK ONLY 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ T PERMANENTLY CLO ED ON E ONE REM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED l`fJ DBA OR FACILITY NAME WHERE TANK IS INSTALLED: I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A OWNER'S TANK I.D.p B. MANUFACTURED BY: U� C. DATE INSTALLED(MO/DAY/YEAR) 4/ D. TANK CAPACITY IN GALLONS: IL TANK CONTENTS IFA-1 IS MARKED,COMPLETE ITEM C. A, 80 MOTOR VEHICLE FUEL OIL B C to REGUAR UNLEADED ❑ 3 DIESEL 0 6 AVIATION GAS 2 PETROLEUM PRODUCT ❑ 1D PREMIUM UNLEADED ❑ 4 GASAHOL T METHANOL 3 CHEMICALPRODUCT ❑ 95 UNKNOWN E] 2 WASTE ❑ iD MIDGAAOE UNLEADED ❑ 5 JET FUEL ❑ 8 M85 ❑ 2 LEADED ❑ 99 OTHER(DESCRIBE M REM D.BELOW) D. IF(A.1)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 APPLIES IN BOX D AND E A. TYPE OF ❑ 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 5 INTERNAL BLADDER SYSTEM ❑ 95 UNKNOWN SYSTEMI® 2 SINGLE WALL ❑ 4 SINGLE WALL IN A VAULT ❑ 99 OTHER E B. TANK J i BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ ? ALUMINUM O 8 100% METHANOL COMPATIBLE W/FRP (PHmary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER C.INTERIOR ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING LINING OR ❑ 5 GLASS LINING E:3-6- UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 10096 METHANOL? YES— NO_ D.EXTERIOR F-1 1 POLYETHYLENE WRAP F—] 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC CORROSION PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE 95 UNKNOWN 99 OTHER E.SPILL AND OVERFILL,etc. SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(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 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 SINGLE WALL A U 2- DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND A U 1 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 T STTEEEELLW/COATING A U 8 100% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION AQ,16 UNKNOWN A U 99 OTHER D. LEAK DETECTION D 1 MECHMG L LINE IFAI( UNE nGNTNEM O 3 CONNNUWE pRER5TI16LL ❑4 ELECTRONIC LINE O 5 AUTOMAnC NAP F] 99 OTHER DE =R TESTING MOMTORMG MK DEFECTOR SHUmO" V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK " RECONCILATIONANUAL INVENTORY ❑ 3 VAOZrMONIITORING ❑ 4 GAUGNGIC TANK AUTOMAT ❑ 5 MONTORINGGROUND WATER ❑6 TESTINGTANK ❑ T MONTORNG INTERSTITIAL ❑ 8 SIR ❑ 9 WEEKLY MANUAL ❑10 MONTHLY TANK ❑ 95 UNKNOWN ❑ 99 OTHER TANK GAUGI NG TESTING VI.TANK CLOSURE``INFORMATION(PERMANENT CLOSURE IN-PUCE) 1.ESTIMATED DATE LAST U404MO/DAYNR) 2.ESTIMATED QUANTITY OF (� 3.WAS TANK FILLED WITH ❑ ❑ /:J SUBSTANCE REMAINING GALLONS INERT MATERIAL? YES NO 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 6 SIGNATURE) LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY# TANK# i STATE LD:# m = PERMIT NUMBER PERMIT APPROVED BYIDATE PERMIT EXPIRATION DATE THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLI ON-FORM A,UNLESS A CURRENT FORMA HAS BEEN FILED. FO�1 C MUST BE COMPLETED FOR INSTALLATIONS. THIS FORM SHOULD BE ACCOMPANIED BY A PLOT PILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THFWRGROUND STORAGE TANK REGULATIONS FORME (6-95) t./ to /yj 77,s