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e gpuer,es STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD 3 a UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B rti COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE CF INFORMATION ❑ 7 PERMANENTLY CLOSED ON SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENCED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED; fi s`,r's '�' - ,��`=� ' `' `, �' ,✓ P' I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A. OWNER'S TANK I.D.0 B. MANUFACTURED BY: C. {LATE INSTALLED(MO/DAY[YEAR) i� it '>, D. TANK CAPACITY IN GALLONS: 11.TANK CONTENTS IF A-1 IS MARKED,COMPLETE ITEM C. v A. '+��.° 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C ❑❑ 1a REGULAR UNLEADED ❑ 3 DIESEL ❑ 6 AVIATION GAS 2 PETROLEUM ❑ 8d EMPTY 1 PRODUCT F�llc b PREMIUM UNLEADED ❑ 4 GASAHOL ❑ 7 METHANOL MIDGAADE UNLEADED ❑ 5 JET FUEL ❑ B M85 ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED ❑ 99 OTHER(DESCRIBE IN ITEM D.EELON!) D. IF(A,i)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 ' 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER E7 _1 5 INTERNAL BLADDER SYSTEM L 95 UNKNOWN A. TYPE OF ❑ SYSTEM ❑ 2 SINGLE WALL ❑ 4 SINGLE WALL IN A VAULT ❑ 99 OTHER B. TANK F71 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑, 8 106% METHANOL COMPATIBLE WIFHP {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 ❑ 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 WRAPA 4 FIBERGLASS REINFORCED PLASTIC CORROSION PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER SPILL CONTAINMENT INSTALLED(YEAR) OVERFIL)r PREVENTION EQUIPMENT INSTALLED(YEAR) E.SPILL AND OVERFILL,et(:- DROP TUBE YES NO STRIKER PLATE YES ')( NO DISPENSER CONTAINMENT YES r4. NO IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION A PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL A j( ' 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)Aetf�FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 5 CONCRETE A U 7 STEEL WICOATING A U 8 100% METHANOL COMPATIBLE WIFRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION 0 1 MECHANICAL LIN€LEAK 2 LINE TIGHTNESS $'CCNTINLOUS INTERSTITIAL 4 ELECTRONIC LINE SAUTCMATIC PUMP [�":'"]� 99 OTHER DETECTOR ❑ TESTING ❑'Y,MONITORING ❑ LEAK DETECTOR �.. SHUTDOWN LJ V.TANK LEAK DETECTION ANNUAL 1 VISUAL CHECK E:32 pECONCILNUAL I�ATEONVNT�RY ❑ 3 MONCITORING —"w:VAOZE4 GAUGINGAUTOMATIG TANK ❑ 5 MONTORINGGROUND WATEH ❑ 6 TESTINGTANK + 7 CONTINUOMONITORING INTERSTITIAL E] 8 SIR ❑ 9 WEEK LY MANUAL E-] 10 MMONTHLY TANK ❑ 95 UNKNOWN El 99 OTHER G TESTING VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) 1.ESTIMATED DATE LAST USED(MOIDAYNR) 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 KNOWLEDGE IS TRUE AND CORRECT TANK OWNER'S NAME DATE (PRINTED b SIGNATURE) LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY# TANK# *j'- STATE k.D:# ❑ C.' � / PERMIT NUMBER PERMIT APPROVED BYIDATE PERMIT EXPIRATION DATE THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLIC ION-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 PILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THreRGROUND STORAGE TANK REGULATIONS FOAM 8 (6.95)