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STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD m� " - e°o UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B - , ° 1 COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED 0SATE ONE REM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ B TANK REMOVED 1 DBA OR FACILITY NAME WHERE TANK IS INSTALLED:"] T' LA I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A OWNER'S TANK 1.D.i B. MANUFACTURED BY: C. DATE INSTALLED(MO/DAY/YEAR) I D. TANK CAPACITY IN GALLONS: II.TANK CONTENTS IF A-1 IS MARKED,COMPLETE ITEM C. A MOTOR VEHICLE FUEL ❑ 4 OIL B. C. 1A REGULAR UNLEADED 3 DIESEL ❑ 6 AVIATION GAS E] 4 GASAHOL ❑ 2 PETROLEUM EJ 80 EMPTY I PRODUCT ❑ 10 PREMUM UNLEADED ❑ ] METHANOL ❑ 10 MIOGRPDE UNLEADED ❑ 5 JET FUEL ❑ 8 M85 ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED ❑ 99 OTHERIDESCRIBEINREMD.BELOM D. IF(A7)IS NOT MARKED. ENTER NAME OF SUBSTAGE STORED C.A.S.0: 111. 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 SYSTEM ❑ 2 SINGLE WALL ❑ 4 SINGLE WALL IN A VAULT ❑ 99 OTHER B. TANK ❑ 1 BARE STEEL ❑ 2 STAINLESS STEEL Njjj:r3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP (Primary Tok) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER C.INTERIOR ❑ I 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'A9 NO— D.EXTERIOR ❑ I POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC CORROSION -1 NONE 95 UNKNOWN 99 OTHER PROTECTION ❑ 5 CATHODIC PROTECTION ❑ ❑ ❑ SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) E.SPILL AND OVERFILL,BEC. DROP TUBE YES� NO_ STRIKER PLATE YES NO_ DISPENSER CONTAINMENT YES 1� NO IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND.BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION U 2 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL A DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND A U I BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)ACU 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 1 AECHN4CAl E. 2 DXE iIG19NE53 3 WIIIMIOUS NIE�IIML 4 E1ECmOMC NNE ❑5 AUTOMATIC NAP ❑ 99 OTHER D. LEAK DETECTION ORFCfgi ❑ r W ❑ MaAraRNo ❑ N,u'&Croe MATWWN V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 RECO CILIATIONORY ❑ 3 MONITORING4 GAUGING AUTOMATANKTIC VADOZE TANK ❑5 MO TER ❑ 8 TE MONITORCONTINUOUS ❑ 3 SIR ❑ 9 WEEKLY MANNUUAL ❑10 MMOON NGY TANK ❑ 95 UNKNOWN ❑99 OTHER VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) IA L E ATED DATE LAST USED(M NR) 2.ESTIMATED TY OF 3.WAS TANK FILLED WITH YES ❑ N �(/ S T REMAINING ONS INERT MATERIAL THIS FORM HAS BEEN COMPLETED UNEQpoNAlLjY OF JUR ,A HE BEST OF MY KNOWL GE,IS TRUE AND CORRECT TANK OWNER'S NAME �0>\ DATE/ (PRINTEDA SIGNATURET _ rG g LOCAL AGENCY USE ONLY THE ST I.D.NUMWFA COMPOSED OF THE FOUR NUMBERS BELOW COUNTY N JURISDICTION k FACILITY M TANK A Of STATE I.D.# m Fl= Ia 3 / F T:Oal ZdIkI.4131 -4 PERMIT NUMBER PER MIT APPROVED BY/DATE PERMIT EXPIRATION DATE I4 ql THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION.FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. FO UST BE COMPLETED FO STALLATIONS.THIS FORM SHOULD BE ACCOMPANIED BY A PLOT PL jfLE THIS FORM WTH THE LOCAL AGENCY IMPLEMENTING THE 1WROUND STORAGE TANK REGULATIONS FOM 5 (695)