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STATE OF CALIFORNIA a STATE WATER RESOURCES CONTROL BOARDUNDERGROUND STORAGE TANK PERMIT APPLICATION-FORM B COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED IT ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED IDEA OR FACILITY NAME WHERE TANK IS INSTALLED: I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A OWNER'S TANK 1.D.p L/ B. MANUFACTURED BY: r'/ v A /•1l!lQ C. DATE INSTALLED(MO/DAV/YEAR) D. TANK CAPACITY IN GALLONS: V O U Q ^ ILTANK CONTENTS IFA-11S MARKED,COMPLETE ITEM C. IVJ' A MOTOR VEHICLE FUEL ❑ 4 OIL B. I. C, REGULAR UNLEADED ❑ 3 DIESEL ❑ 6 AVIATION GAS F-] 2 PETROLEUM ❑ BO EMPTY ENIl PRODUCT ❑ lb PREMIUM UNLEADED ❑ 4 GASAHOL ❑ 7 METHANOL ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 1c MIDGRADE UNLEADED ❑ 5 JET FUEL ❑ 8 M85 ❑ 2 LEADED ❑ 99 OTHER(DESCRIBE IN TEM 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 LIX' DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 5 INTERNAL BLADDER SYSTEM ❑ 95 UNKNOWN SYSTEM I❑ 2 SINGLE WALL ❑ 4 SINGLE WALL IN A VAULT ❑ 99 OTHER L B. TANK W 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP (Primary 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 E6 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH IDD% METHANOL? YES_ NO ' D.EXTERIOR ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC CORROSION PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE 0 9 UNKNOWN ❑ 99 OTHER E.SPILL AND OVERFILL,etc. SPILL CONTAINMENT IIT LLED(YEAR) OVERF VENTION EQUIPMENT INSTALLED(YEAR) DROP TUBE YES NO RIK 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&2 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL A(J 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)AV 4 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL W/COATING A U B 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 fT1.1NM TrIGIL UNE LEVL ❑2 UNE TreHTNSSS ❑3 CONRMUWS INTERSRINL O 4 ELECTRONIC UNE AUTOMATIC PUW l� OETE"A TEST G MOMTORING LEAK DETECTOR SHUR m ❑ 99 OTHER V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 MANUAL RECONCILIATION ORV ❑ 3 VADOZE MONITORING ❑ 4 GAUGING AUTOMATIC TANK ❑5 GROUND MONITORINGTER ❑ B TESTING ❑ 7 CONTNUOUS MONITORING INTERSTITIAL ❑ 8 SIR ❑ 9 WEEKLY MANUAL ❑ 10 MONTHLY TANK ❑ 95 UNKNOWN ❑ 99 OTHER TANK GAUGING TESTING VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PUCE) 1.ESTIMATED DATE LAST USED(MO/DAYNR) 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 TO THE BEST OF MY K OWLEDGE,IS TRUE AND CORRECT TANK OWNER'S NAME DATE (PRINTED B SIGNATURE) blol /✓n oO LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY# TANK# STATE I.D:# m O PERMIT NUMBER PERMIT APPROVED BYIDATE PERMIT EXPIRATION DATE i THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPL ON-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. C MUST BE COMPLETED FOR INSTALLATIONS. THIS FORM SHOULD BE ACCOMPANIED BY A PLOT IW FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THJWRGROUND STORAGE TANK REG TIONS FORM B (6.95) ,�