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• � sWeccs ' STATE OF CAUFORNIA - STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION -FORM B c r COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. 7 PERMANENTLY CLOSED ON SITE ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION 6 TANK REMOVED MU4 ERMIT 6 TEMPORARY TANK CLOSURE PERMIT ❑ < AMENDED PERMIT ANK IS INSTALLED: I. TANK DES�G.# COMPLETE ALL ITEMS– SPECIFYIFUNKNOWN B MANUFACTURED BY: UN�LNO�� A OWNER'S TA3 5 D. TANK CAPACITY IN GALLONS: C. DATE INSTALLED(MOI)AYNEARI il.TANK CONTENTS IF A-i IS MARKED.COMPLETE TEM C. ❑ 6 AVIATION GAS 18 REGULAR UNLEADED ❑ 3 DIESEL n 1 MOTOR VEHICLE FUEL ❑ d OIL S. C. ❑ lb PREMIUM UNLEADED ❑ K GASAHOL ❑ 7 METHANOL A V❑" 2 PETROLEUM ❑ 80 EMPTY ❑ 7 PRODUCT ❑ 1c MIDGMDE UKFApED 5 JET FUEL ❑ 8 M� ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED 99 OTHER(DESCRIBE W TEEM D.BR.ON1 C.AS.a: D. IF(A1)IS NOT MARKED. ENTER NAME OF SUBSTANCE STORED 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 ❑ 5 INTERNAL BLADDER SYSTEM ® 95 UNKNOWN A. TYPE OF ❑ ❑ SINGLE WAIL IN A VAULT ❑ 99 OTHER SYSTEM 2 SINGLE WALL S. TANK ❑ 1 BARE STEEL E] 2 STAINLESS STEEL E] 3 FIBERGLASS C34 STEEL CUD W1 FIBERGLASS REINFORCED PLASTIC ❑ ❑ 8 POLYVINYL CHLORIDE ❑ 7 ALUMINUM � 8 100%METHANOL COMPATIBLE W/FRP MATERIAL 5 CONCRETE (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL � 95 UNKNOWN ❑ 99 OTHER ❑ 2 ALKYD LINING ❑ 3 EPDXY UNING E] 4 PHENOLIC LINING C.INTERIOR ❑ 1 RUBBER LINED UNKNOWN ❑ 99 OTHER LINING OR ❑ 5 GLASS UNING ❑ 6 UNLINED 95 COATING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO— D.EXTERIOR ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP 6 FIBERGLASS REINFORCED PLASTIC CORROSIONDTIDN ❑ 91 NONE ®95 UNKNOWN ❑ 99 OTHER PROTECTION ❑ 5 CATHODICPROTE SPILLCONTAINMENT IN SUELED(YEAR)`'aL TQIKFQP1 OVERFILL PREVENTNXI EIXHPMENENSER CON(YEAR)N YES E.SPILL AND OVERFILL,etc. NO_ STRIKER PLATE YES__ NO DISPENSER CONTAINMENT YES_ NO DROP TUBE YES IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND.BOTH IF APPLICABLE =DETECTION PE A U 1 SUCTION A g 2 PRESSURE A U 3 GRAVITY A U < FLEXIBLE PIPING A U 99 OTHER B. TION A U 1 SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A0 95 U)#DgWN A U 99 OTHER AND A U 1 BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLOfa�(PVC)A U A FIBERGLASS PIPE N A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL WICOATING A U 8 100% METHANOL COMPATIBLE WIFRP N A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER 1 YEfilHafJ1 UNE U'vUt 3WMMAWSID@6D111L , PUPCTION ❑ pElE1,TGR ❑ TE51NG ❑ uoNrou�G IFAK r,ETaaR 9Mr',ptl © 99 OTHER JjCYe4l J V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 q �Y ❑ 3 ❑ l MATANK WATER ❑ e ANNUALTANK MANUAL INVENTORY MONITORING AUTOMATIC TESTING ❑ T CONI UCS INTERSTITIAL ❑ 8 SIR ❑ 9 WEEKLYMATANKGAUG-NGO ❑10 MONTHLY TESTING TANK ® 95 UNKNOWN ❑99 OTHER VI.TANK CLOSURE INFORMATION(PERMANENT cLosURE IN-PLACE) 1.ESTIMATED tLASTKell MOIDAY/YR) 2.ESTIMATEDWANTITY OF 3.WAS TANKFILLED WITH YESSUBST E REMAINING GALLONS INERT MATERIAL?THIS FORCOMPLETED UNDER P L OF P JUY ATO TH�E BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT TANK AfQJ' � DATE _(PRINTr� ((fJ LOCAL AGENCY USE ONLY THE STATE I.D.N MBER I MPOSED OF THE FOUR NUMBERS BELOW COUNTY# JU SDIc-nONN FACILITY#-377& TANK# OD STATE LDJ mr M IP11110 6 PERMIT NUMBERPERMIT APPROVED BY/DATE PERMITEXPIRA ON TE I zb)y yIs(ST THIS FORM MUST BE ACCOMPANIED BY PERMITAPPUCATIOflN A,UNLESS ACURRENT FORM HAS BEEN FILED. FORM CBE COMPLETED FOR INSTALLATION$, THIS FDR SHOULD BE ACCOMPANIED BY A PLOT PLAN. v IS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDE WUNO STORAGE TANK REGULATIONS FORM B (6-95)