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STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION FORM B A �; o COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM, LMARKONLY a 1 MEW PERMIT 3 RENEWAL PERMIT ❑ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDf=D PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED ON SITE ❑ 5 TEMPORARY TANK CLOSURE O 8 TANK REMOVED R FACILITY NAME WHERE TANK IS INSTALLED: '72 I. TANK DESCRIPTION COMPLETE ALL ITEMS-- SPECIFY IF UNKNOWN A- OWNER'S TANK I.0.# 0. MANUFACTUREDfGALLONS: '71. x C. DATE INSTALLED(MOIDAYIYEARI EE D. TANK CAPACITYe�uC> II.TANK CONTENTS IF A-1 IS MARKED,COMPLETE ITEM C. A. 1 MOTOR VEHICLE FUEL 4 OIL 3 C' 1a REGULAR UNLEADED ❑ 3 DIESEL ❑ 6 AVIATION GAS 2 PE=TROLEUM ❑ 80 EMPTY 1 PRODUCT ❑ 1b PREMIUM UNLEADED ❑ 4 GASAHOL ❑ 7 METHANOL ❑ 3 CHEMICAL PRODUCT 95 UNKNOWN 2 WASTE ❑ 1c MIDGRADE UNLEADED ❑ 5 JET FUEL 9 M65 ❑ 2 LEADED 99 OTHER(DESCR]BE IN ITEM D.BELOW) D. IF(A.1)!S NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S.#: III. TANK CONSTR CTION MARK ONE ITEM ONLY IN BOXES A,3,AND C.AND ALL THAT APPLIES IN BOX D AND E A. TYPE OF 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LEANER ❑ 5 INTERNAL BLADDER SYSTEM ❑ 95 UNKNOWN SYSTEM ❑ 2 SINGLE WALL ❑ 4 SINGLE WALL IN A VAULT ❑ 99 OTHER B. TANK ❑ 1 BARE STEEL 2 STAINLESS STEEL ❑ 3 FIBERGLASS 4 STEEL CLAO W FFIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM S 106% METHANOL COMPATIBLE WIFRP (PrimmTank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER C.INTERIOR ❑ 1 RUBBER LINED 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING LINING G 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 CORROSION ❑ 3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER E.SPILL AND OVERFILL,etc. SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL REVENTION 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,DOTH 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� 4 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL WICOATING A U PB 100% METHANOL COMPATIBLE WIFRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN p U 99 OTHER D. LEAK DETECTION NECHANICAL LINE LEAK ❑2 LME TIGHTNESS 3 CONTINUOUS INTERSTITIAL ❑4 ELI I 'l l C L ANE 5 AUTOMATIC PUMP DETECTOR TESTING MONITORING LEAK DETEOTOR SHUTDOWN ❑ 99 flT}{ER V.TANK LEAK DETECTION ❑ Y VISUAL CHECK ❑ 2 MANUARECONL INVENTORY ❑ 3 VADOZE ING ❑ 4 AUTOMATIC TANK ❑ 5 GROUND WATER 6 ANNUALTANK 7 MONITOHWG US INTERSTITIAL ❑ 6 SIR ❑ 9 WEEKLMONITY RMANUAL ❑ 10 MONTGAUGHLY TANK MONITORING TESTING TANK GAUGING TESTING ❑ 95 UNKNOWN ❑99 OTHER VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE fN-PLACE) 1,ESTIMATED DATE LAST USED(MOI 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH SUBSTANCE REMAINING GALLONS INERT MATERIAL 7 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 IPRINTEIJ 6 SIGNATURE) DATE LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY# TANK# STATE I.D.# PERMIT NUMBER PERMIT APPROVED BVlDATE PERMIT EXPIRATION DATE V THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLE ION-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED, FO M C MUST BE COMPLETED FOR INSTALLATIONS. THIS FORM SHOULD BE ACCOMPANIED BY A PLOT FORLE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THIWRGROUND STORAGE TANK REGULATIONS FORM 3 ;6-95)